Cervical Arterial Dysfunction: Knowledge and Reasoning For Manual Physical Therapists

[ CLINICAL COMMENTARY ]
ROGER KERRY, MSc, MMACP, MCSP¹7B7D@$J7OBEH"MSc, MCSP²
Cervical Arterial Dysfunction:

Knowledge and Reasoning for
Manual Physical Therapists
7
dverse events associated with manual-therapy interventions of serious event following manipulative
Downloaded from www.jospt.org at on December 10, 2020. For personal use only. No other uses without permission.
have been the concern of clinicians for many decades. Arguably, thrust. Restricting focus to this single
clinical question, “Will there be a neuro-
the most reported and discussed adverse event is that related
vascular event following the manipula-
to cerebrovascular accident as a result of vertebrobasilar tion?” prevents proper evidence-informed
insufficiency (VBI). VBI is a specific and rare occurrence occasionally analysis of the patient presentation. We
attributed to certain manual therapy techniques of the cervical spine. approach the topic within a different
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Guidelines for practice have been available for the last 2 decades to assist paradigm: the consideration of clinical
and experimental literature related to
clinical decision making with regard to arterial system perfusing the hind-brain cervical arterial disease (pathology and
VBI and manipulation techniques. 32,53 (vertebrobasilar), and the anterior arteri- presentation), and how this knowledge
This paper takes the perspective that al system supplying blood to the cerebral can be utilized in manual-therapy clini-
VBI is only 1 example of a number of pa- hemispheres and eye (internal carotid ar- cal decision making. A consistent theme
thologies affecting the arterial structures teries). As such, the term cervical arterial within this literature is how both verte-
of the cervical region. Pathologies may dysfunction (CAD) is used to represent brobasilar and internal carotid dysfunc-
range from transient mechanical occlu- the anatomical and pathological spec- tion may, at an early stage, present with
Journal of Orthopaedic & Sports Physical Therapy®
sions, intimal tearing (dissections), to trum of events. very few signs and symptoms other than
frank atherosclerotic thromboembolic Furthermore, this paper proposes that head and neck pain. Thus, an interesting
events leading to a stroke. Such patholo- the issues around this clinical topic are clinical challenge is offered to the manual
gies are evident in both the posterior wider than simply considering the chance therapist—vascular differential diagnosis
of head and neck pain.
TIODEFI?I0 This clinical commentary provides mimic neuromusculoskeletal cervicocranial syn- The main focus of this paper there-
evidence-based information regarding adverse dromes. Invariably, the 2 conditions coexist. This fore concerns what information can be
cerebrovascular events in the context of manual reasoning presupposes that some patients who gathered by the clinician to determine a
therapy assessment and management of the cervi- have poor clinical outcomes, or a serious adverse potential vascular cause of head and neck
cal spine. Its aim is to facilitate clinical decision response to treatment, may be those who actually pain. It is also proposed that the pres-
making during diagnosis and treatment of patients present with undiagnosed vascular pathology. We
ence of signs and symptoms indicative of
presenting to the therapist with cervicocranial use 2 case reports to demonstrate how incorpo-
pain. Rather than focusing on a traditional view of vascular disease need not necessarily be
rating vascular knowledge into clinical reasoning
premanipulative testing as the cornerstone for de- processes may influence clinical decision making. a contraindication to treatment. A rea-
cision making, we present information concerning soned risk-benefit analysis needs to be
TB;L;BE<;L?:;D9;0 Level 5. J Orthop Sports
the clinical presentation of specific vascular condi- undertaken for the best clinical decision
Phys Ther 2009;39(5):378-387. doi:10.2519/
tions. Additionally, we discuss the assessment and to be made. These issues are discussed
jospt.2009.2926
management of musculoskeletal pain in the pres-
within the context of 2 case reports.
ence of risk factors for cerebrovascular accident. It TA;OMEH:I0 carotid artery, cervical spine,
is proposed that vascular “red flag” presentations neck, vertebral artery The first case scenario represents mis-
diagnosis of a serious vascular trauma.
1
Associate Professor, Division of Physiotherapy Education, University of Nottingham, Nottingham, UK. 2Physiotherapy Lead, Clinical Specialist, Nuffield Health, Fitness and
Wellbeing Centre, Nottingham, UK. Address correspondence to Roger Kerry, Division of Physiotherapy Education, University of Nottingham, Hucknall Road, Nottingham, NG5
1PB, UK. E-mail: roger.kerry@nottingham.ac.uk
378 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy
The second case focuses on the integra-
tion of vascular pathology knowledge
in the decision-making process for the
manual therapy assessment and man-
agement of a patient with significant risk
factors for stroke. It should be noted that
the first case report is not an exemplar of
standard of care. Rather, this case is used
as a vehicle to highlight classically under-
considered areas within manual therapy.
Conversely, the second case report repre-
sents a good example of how the clinician
was able to develop an evidence-informed
risk-benefit analysis. This second case is
used to demonstrate how information re-

garding risk needs to be contextualized by
the potential benefits of an intervention
for the best clinical decision to be made.
The 2 case reports are included in this
paper to present relevant information <?=KH;'$Typical pain distribution relating to extracranial vertebral artery dissection: ipsilateral posterior upper
cervical pain and occipital headache. Reprinted from Manual Therapy, 11(4), Kerry and Taylor, Cervical arterial
regarding CAD in a meaningful manner. dysfunction assessment and manual therapy, 243-253. Copyright 2006, with permission from Elsevier.
It is hoped that these cases can be used
as learning tools and narratives that will pathology, it may have been possible for vical segmental instability or VBI (eg,
benefit future clinical experiences. the therapist to recognize an alternative dizziness, diplopia, drop attacks, dys-
It must be considered that the area of cause of signs and symptoms. The case arthria, dysphagia, facial numbness,
CAD (including VBI) beholds a paucity is described below, and discussion on nystagmus, nausea). Her present use
of absolutes in terms of guidelines. Each pathology and presentation of the verte- of medication included Paracetemol, as
clinical decision should embrace this un- brobasilar system follows. needed, and statins.
certainty and the clinician should aim to A 40-year-old female clothing factory Physical examination revealed no
make the best decision, based on a bal- worker presented to Physiotherapy with neurological deficit; however, mechani-
ance of probabilities, rather than aiming left-sided head and neck pain (<?=KH; cal movement dysfunction involving the
to make the “right” decision. With this '). She reported a 3-day history of the upper- and mid-left cervical spine was
in mind, it must be remembered that symptoms, which began when she quick- noted. Formal VBI testing (functional
although the exact prevalence of these ly rotated her neck to the right at work. positional testing)53 was not performed,
cases (ie, patients presenting to manual The symptoms progressively worsened. as the clinician did not intend to perform
therapists with CAD) is unknown, it is The pain was described as a dull con- manipulative techniques, nor had the
likely to be very low. As such, initially, stant ache, rising to a sharp pain of 7/10 patient reported any subjective indica-
the chance of a patient’s head and neck severity on a numerical rating scale with tors for VBI. Over 6 days the patient was
pain being caused by frank arterial dys- neck rotation to the right. Cervical spine treated on 3 occasions, with a combina-
function is very low. This low probability extension worsened the symptoms mild- tion of passive mobilization techniques,
may or may not be affected as a result of ly. The pain was eased by rest and Par- electrotherapy modalities, and exercise
unfolding information derived from the acetemol. The patient reported 2 road prescription (no end-of-physiological-
history intake and physical examination. traffic accidents in the last 18 months, range manual-therapy techniques or ex-
resulting in prolonged periods of head ercises were performed).
97I;H;FEHJ' and neck pain, successfully managed At the start of the last therapy ses-
by Physiotherapy with complete resolu- sion, the patient reported no improve-
tion of symptoms. The present pain was ment in original symptoms and an onset
J
his case presents an unfor-
tunate episode of misdiagnosis. described as “unlike previous episodes.” of new symptoms, including “feels like
Superficial analysis of the clini- Past medical history included periods of might be sick,” “throaty,” “feels faint,”
cal presentation may suggest a benign stress resulting in time off work and high especially after performing prescribed
musculoskeletal dysfunction. However, blood pressure. She reported no classic exercises. Prior to treatment on this fi-
by considering knowledge of vascular signs and symptoms of either upper cer- nal session, a VBI positional test was
journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 379
performed (10-second end-range posi-
Presentations of Vertebral
tioning in left and right rotation), meet- J78B;'
Artery Dissection*
ing the minimum requirements of the
Australian Physiotherapy Association Ded_iY^[c_YBeYWbI_]diWdZIocfjeci
Guidelines,53 which did not cause any ?fi_bWj[hWbfeij[h_ehd[YafW_d%eYY_f_jWb^[WZWY^[
symptoms. Therapeutic ultrasound ther- 9(#9,Y[hl_YWbheej_cfW_hc[djhWh[
apy was provided, together with a review ?iY^[c_YI_]di%Iocfjeci
of home exercises. The patient failed to >
_dZ#XhW_dJ?;Z_pp_d[ii"Z_fbef_W"ZoiWhj^h_W"Zoif^W]_W"ZhefWjjWYai"dWki[W"doijW]cki"\WY_WbdkcXd[ii"WjWn_W"
attend her next appointment and was lec_j_d]"êWhi[d[ii"beiie\iêhj#j[hcc[ceho"lW]k[d[ii"ôfejed_W%b_cXm[Wad[iiWhcehb[]"Wd^_Zhei_ibWYa
of facial sweating, hearing disturbances, malaise, perioral dysthesia, photophobia, papillary changes, clumsiness and
discharged after a further 4 weeks of agitation)
no contact with the Department. Upon >_dZ#XhW_dijhea[[]"MWbb[dX[h]ÊiiodZhec["beYa[Z#_diodZhec[
longer-term follow-up inquiry it was Abbreviation: TIE, transient ischemic event.
revealed that the day following her last * Nonischemic symptoms can precede ischemic events by a few days to several weeks. Reprinted from
Manual Therapy, 11(4), Kerry and Taylor, Cervical arterial dysfunction assessment and manual
therapy session she had suffered an
therapy, 243-253. Copyright 2006, with permission from Elsevier.
acute stroke as a result of left cerebella

infarction related to a left vertebral ar-
tery dissection between the C1 and C2 mon initial presentation of structural of Coman.12 Unreasoned adherence to
vertebral levels (V2-V3 portion of the trauma to the vertebral arteries.3,5,11,59,65 these cardinal “classic” signs and symp-
vertebral artery). On rare occasions, cervical nerve root toms can, however, be misleading and
impairment (usually C2 to C6) can be result in an incomplete understanding
:_iYkii_ede\<_hij9Wi[H[fehj present as a result of local neural isch- of patient presentations. More detailed
This case highlights the misdiagnosis emia.14 Migraine-type headache has been evidence from medical literature shows
and subsequent mismanagement of a reported as a strong predictor of verte- that the typical presentation of verte-
patient who most likely presented with bral artery injury.4,58 It is also known that brobasilar dysfunction is not always in
a vascular pathology at initial consulta- cervical spine rotation stresses the con- line with this classical picture. Although
tion. It is argued herewith that, with the tralateral vertebral artery, and this is a these classic indicators may be present,
consideration of vascular anatomy and potential mechanism of vertebral artery there are further signs and symptoms to
pathology, a more detailed examination injury.2,20,31,38,39,47,49,51,56 While this pre- consider (J78B;').3,50,59
would have resulted in more accurate sentation and mechanism of injury is a It is rare for CAD to manifest in only
clinical decisions. It is unlikely that a de- common manifestation of injury to nu- 1 sign or symptom, and isolated dizziness
finitive diagnosis could have been made merous other cervical structures, given or transient loss of consciousness are of-
at initial assessment. However, the lack of the above knowledge, and the awareness ten misattributed to posterior circulation
response to treatment, contextualized by of the serious potential sequelae of vas- ischemia.59 Dizziness is often reported as
cardiovascular background and presen- cular trauma, it is reasonable to suspect being one of the most common symp-
tation of the patient, could have alerted such a presentation as a vascular injury. toms of VBI.13 However, there have been
a re-examination and possible referral The initial presentation in this case is cases reported when dizziness was not
to a specialist (neurologist or vascular representative of what is known about present. The nature of dizziness can be
specialist) for further investigation. We vertebral artery injury. a differentiating factor in establishing a
also suggest that the clinical issue is one As stated above, the initial presenta- vascular versus nonvascular cause. Typi-
of misdiagnosis and not causation (the tion of vertebral artery injury is com- cally, dizziness secondary to posterior
stroke was not caused by physiotherapy monly head and neck pain. This phase circulation dysfunction does not present
interventions). of injury is described as a nonischemic as frank vertigo, although some authors
phase (ie, local, somatic responses3) and have suggested this could occur.59 Vas-
FWjj[hdH[Ye]d_j_edWdZ may last from a few minutes to a few cular dizziness occurs as a result of neck
IocfjecWjebe]o weeks. If the injurious process were to rotation, and does not improve with re-
In the early stages, vertebral artery pa- continue, the pathology would develop peated movement. This pattern differs
thologies commonly present as neuro- into an ischemic phase. Classically, the from nonvascular vestibular dizziness,
musculoskeletal symptoms, often isolated signs and symptoms related to hind- which often has a short latency and can
neck and head pain without commonly brain ischemia are considered as the improve with repeated movement. Nine
described VBI symptoms.3,40,63 Upper “five Ds” (dizziness, diplopia, dysarthria, days posttrauma, this patient presented
cervical pain accompanied with occipital dysphagia, and drop attacks) and “three with new symptoms indicative of hind-
headache has been reported as a com- Ns” (nausea, numbness, nystagmus) brain ischemia.
Predisposing Factors and Physical
Diagnostic Utility of the Vertebrobasilar
Examination TABLE 2
Insufficiency (VBI) Test*
The authors of a small number of man-
ual therapy reports have suggested that Author Sensitivity Specificity LR+ LR–
vertebral artery injury related to man- Cote et al 1996 0.00 0.86 0.00 1.16
ual therapy is a random, unpredictable Rivett et al 2000 0.10 0.39 0.16 2.30
event with no predictive indicators.18,21 It Kerry et al 2003 0.31 0.48 0.59 1.44
should be noted that “manual therapy” is Kerry 2006 0.10 0.44 0.16 2.30
very rarely defined in many papers and * LR+ is the likelihood ratio for a positive test. LR– is the likelihood ratio for a negative test. The fur-
may refer to any technique from soft ther away from 1 (on a scale of 0.001 to 1000) the LR is (LR+, above 1; LR–, below 1), the better the test
at ruling the condition in or out. Above 10 would be considered a good LR+, and below 0.01 would be
tissue massage to high-velocity thrusts. considered a good LR–. All readings from the studies in the table would indicate poor and inconsistent
However, other authors suggest that pre- findings for the diagnostic utility of the VBI test.
diction of cerebrovascular events can be
made. Specifically for manual therapy- in response to endothelial damage. 9 Functional positional tests of the cer-
related adverse events, several predictors Either pathological state may lead to vical spine are commonly used to iden-
have been reported, including aortic root stroke.22,44,55 Arterial dissection may oc- tify the presence of VBI.19,53 The purpose
diameter, migraine, relative common ca- cur after trivial trauma to the vessel or of establishing whether or not a patient
rotid artery diameter change during the spontaneously. This may be related to has VBI is obviously of great importance
cardiac cycle, and trivial trauma (ie, as- pre-existing congenital weakness of the to health professionals from whom a pa-
sociated with cervical spine manual ther- vessel wall or acquired vascular pathol- tient has sought help for cervical pain.
apy), plasma homocysteine, and recent ogy (atherosclerosis). Atherosclerosis is The underlying mechanical principle of
infections.58 Vertebral artery accidents considered to be a fundamental predis- these tests has been the subject of a num-
have been reported to be 5 times more position for cervicogenic stroke.8,27,28,36,37 ber of research reports. Many blood flow
likely to occur if a patient received man- Atherosclerosis is an inflammatory pro- studies have demonstrated a reduction in
ual therapy within 1 week of the stroke, cess associated with a number of factors, blood flow in the contralateral vertebral
and individuals with a vertebral artery including hypertension, hypercholes- artery during rotation.2,20,31,39,38,47,48,51,56,67,68
related stroke are 5 times more likely terolemia, hyperlipidemia, hyperhomo- Most of this work has been undertaken
to have had received manual therapy cysteinemia, diabetes mellitus, genetic on asymptomatic subjects. Some au-
than the control group.57 Other reports clotting disorders, infections, smoking, thors have used these studies to support
have concluded that arterial dissection free radicals, direct vessel trauma, and the validity of screening tests. In other
is 5 times more likely to occur if manual iatrogenic causes (surgery, medical words, these studies demonstrate that
therapy had been administered within 30 interventions).22,23,36,37,55 rotation changes blood flow; therefore,
days prior to, and twice as likely to have It is important for the clinician to ap- the test is valid. The tests may be valid in
had increased neck/head pain preceding, preciate that hypertension is positively that they may alter blood flow, but there
the stroke.60 These studies concluded that correlated to disease and dysfunction is little consistent evidence relating these
vertebral artery dissection was indepen- of the cervical arteries.16,24,34,43,62 Conse- changes to alterations in symptoms (eg,
dently associated with stroke and in- quently, this may indicate that recog- a patient could have significant reduc-
creased neck/head pain. nition of hypertension by the clinician tion in blood flow but no VBI symptoms,
Manual therapy specific studies are, could be important when assessing the and vice versa). This makes the specific-
however, scarce, have small subject likelihood of potential CAD. The history ity and sensitivity of these tests poor and
numbers, and possess numerous limi- of the patient in this case report indi- variable, affecting their diagnostic utility
tations that make forming clear judg- cated several risk factors for vascular and, therefore, clinical usefulness (TABLE
ments about predisposing factors and disease: a state of hypertension (subjec- 2).13,25,26,52
predictors of adverse events difficult tively reported), hypercholesterolemia In this case report, even though the
and inconclusive.8 A wider, more holis- (she reported that she was taking statins patient was reporting signs of possible
tic review of the literature helps to fa- in her drug history), possible trauma to hind-brain ischemia (9 days posttrau-
cilitate knowledge and understanding of vessel wall (mechanism of injury being ma), the response to functional position-
CAD. Trauma to cervical blood vessels 2 road traffic accidents), and headache. ing testing was still negative. Clinically, a
is generally classified as either dissec- Further questioning could have been negative response does not rule out the
tion (intimal tearing), resulting from directed towards gaining information presence of the pathology.
direct trauma to the vessel, or localized about other known predisposing factors Based on available information, it
thrombogenesis and embolus formation for vascular disease. would be justifiable to reconsider the tra-
ditional approach to physical examina- Many of the symptoms related to hind- which she believed was related to the
tion for vertebral artery pathology. Based brain ischemia are related to dysfunc- arm pain. For 6 years she had received
on the atherosclerotic theory, measure- tion of cranial nerves, whose origins are intermittent episodes of cervical manual
ment of blood pressure in the clinic is a within the territory of the vertebrobasi- therapy when her pain worsened. These
clear way to gather useful information lar system (except cranial nerves I and episodes of therapy would dramatically
about the possible hypertensive state of II). Being sensitive to changes in blood reduce her severe neck and arm symp-
the patient. Blood pressure testing can supply, it is likely that the cranial nerve toms. A local change in resource policy
be used as either a measure of regu- dysfunction will manifest early on in the had resulted in this treatment option stop-
lar state of hypertension for a patient ischemic phase. Cranial nerve testing is, ping. Because she had stopped receiving
or as an indicator for vascular trauma, therefore, proposed as a firm part of the treatment, the patient reported a severe
which may result in acute alterations in clinical examination for vertebral artery and disabling increase in symptoms. She
pressure.20,33,41 dysfunction. now described a very poor quality of life,
It is important to appreciate that, al- In summary, there were indicators including inability to sleep and numerous
though hypertension is undoubtedly a in this patient’s history and background side effects from ineffective medications
strong predictor of cardiovascular dis- to warrant the inclusion of a vascular prescribed to relieve her pain. The patient
ease, interpretation of readings must be hypothesis in the diagnostic reasoning was referred for third-party specialist
in context of other findings and sound process. Standard of care in this instance consultation as part of an appeal by the
logical reasoning. Vascular disease is would have included the focused testing patient and her family to have the man-
an interplay between various factors, of of such a hypothesis. This should include ual therapy treatment regime reinstated.
which high blood pressure is just one (al- further questioning (cardiovascular pro- Upon consultation, the patient revealed
beit a consistently important one). Blood filing) and understanding the clinical that she had 2 episodes of cerebrovascu-
pressure is a graduated, continuous mea- presentation in the context of vascular lar accident (stroke) 8 and 9 years ago.
sure and, as such, cannot have a thresh- pathology. Additionally, informed inter- Vascular examination at the time of the
old.41 The clinician should bear these pretation of a small number of clinical last stroke demonstrated 70% occlusive
points in mind during clinical decision tests would help in forming a judgment disease of her left internal carotid artery
making. It is, therefore, unreasonable on the chance of vascular pathology being (abnormal). On examination, her blood
to state that all patients with hyperten- present. To reiterate a critical point, an pressure was 186/75 (hypertensive), al-
sion and neck pain should be referred to absolute diagnosis cannot be made by the though the patient reported significantly
a medical specialist. Hypertension and physiotherapist—a clinical decision based lower home readings (around 126/76
neck pain are only 2 of the many factors on the balance of probabilities would be [normotensive]). Doppler examination
that influence the decision on probability the aim of this standard of care. revealed triphasic flow (normal) in both
of vascular pathology. The concept and the left and right internal carotid arteries,
terminology of hypertension are conten- 97I;H;FEHJ( and the left and right vertebral arteries.
tious.33 But, as a general guide, hyper- The flow in the left internal carotid artery
tension is usually indicated by a systolic was significantly more turbulent (indica-
J
his case represents a good rea-
blood pressure greater than 140 mmHg soning process whereby a clinical tive of abnormal flow which would relate
and a diastolic blood pressure greater decision is reached to continue to the known occlusive disorder). Flow
than 90 mmHg.17 Data regarding scaled with treatment in the presence of high in all 4 vessels was unaffected by cervi-
risk is equally as clinically useful. There is cardiovascular risk factors. The point of cal extension or rotation, although the
a positive correlation between increased this case is to highlight that the potential amount of range of motion available was
systolic and diastolic pressure and risk risks of interventions should be judged in markedly limited. There were no positive
of stroke (the higher the pressure, the the context of potential benefits. Careful findings on neurological testing (cranial
greater the risk).1 This would mean that examination and consideration of risk or peripheral). Despite the apparent sig-
a patient with blood pressure of say factors are, of course, essential. Equally nificant cerebrovascular risk factors, a
190/100 mmHg is at greater risk than necessary is the consideration of the po- decision to reinstate manual therapy was
a patient with that of 160/95 mmHg. tential negative impact on quality of life made. The reasoning for this decision is
Thus, the risk is different, even though of withholding treatment. discussed below.
they are both hypertensive. However, to A 79-year-old female presented for
reiterate, the actual utility of these data consultation with a 20-year history of :_iYkii_ede\I[YedZ9Wi[H[fehj
in isolation is limited, as the true clinical left arm pain resulting from surgery for This case represents a challenging clini-
risk is dependent on additional coexist- removal of a malignant histiocytoma. She cal decision-making process. The patient
ing factors. reported a 7-year history of neck pain, may gain significant benefit from the re-
Clinical Features of Internal
J78B;)
Carotid Artery Dissection*
Ded_iY^[c_YbeYWbi_]di%iocfjeci
>ehd[hÊiiodZhec[
FkbiWj_b[j_dd_jki
9hWd_Wbd[hl[9DfWbi_[iceijYeccedbo9D?NjeN??
Less common local signs and symptoms include:
?fi_bWj[hWbYWhej_ZXhk_j
IYWbfj[dZ[hd[ii
D[Yaim[bb_d]
9DL?fWbio
EhX_jWbfW_d
7d^_Zhei_i\WY_WbZhod[ii
?iY^[c_YY[h[XhWbehh[j_dWbi_]di%iocfjeci
JhWdi_[dj_iY^[c_YWjjWYaJ?7
?iY^[c_Yijhea[kikWbboc_ZZb[Y[h[XhWbWhj[hoj[hh_jeho
H[j_dWb_d\WhYj_ed
7cWkhei_i\k]Wn
* Nonischemic signs and symptoms may precede cerebral/retinal ischemia by anything from a few
<?=KH;($Typical pain distribution relating to
dissection of internal carotid artery: ipsilateral front-
days to over a month. Reprinted from Manual Therapy, 11(4), Kerry and Taylor, Cervical arterial dys-
function assessment and manual therapy, 243-253. Copyright 2006, with permission from Elsevier j[cfehWb^[WZWY^["WdZkff[hY[hl_YWb%c_ZY[hl_YWb
pain. Reprinted from Manual Therapy, 11(4), Kerry
and Taylor, Cervical arterial dysfunction assessment
instatement of manual therapy interven- like vertebral artery trauma discussed and manual therapy, 243-253. Copyright 2006, with
tion. However, she has a strong history of above, can manifest as nonischemic signs permission from Elsevier.
cervical vascular disease and has demon- and symptoms (somatic pain related to
strable internal carotid artery disease. local injury). As in vertebral artery pa- sensitivity are described as carotidynia.
Superficially, she presents as a high risk thology, these local signs and symptoms Cranial nerve palsies and Horner’s
for cerebrovascular accident. The clinical can precede cerebral ischemia (transient syndrome are often pathognomonic of
reasoning challenge is one of risk-benefit ischemic attack, stroke, or retinal isch- internal carotid artery pathology, espe-
analysis. The fact that she has received emia) by anything from less than a week cially if the onset is acute. The hypoglos-
previous treatment with no adverse ef- to beyond 30 days.7,69 There is, therefore, sal nerve (CN XII) is the most commonly
fect might be an initial line of support a period when a patient with internal affected followed by the glossopharan-
for continuing manual therapy. However, carotid artery dissection may present geal (CN IX), vagus (CN X), or accessory
this inductive inference is by no means to the manual therapist with signs and (CN XI) nerves.3,69 However, all cranial
a secure argument for ensuring that no symptoms that may mimic a neuromus- nerves (except the olfactory nerve) can
adverse events will occur in the future. culoskeletal presentation.63 J78B;) shows be affected.69 If the dissection extends
Detailed analysis and examination, utiliz- the classic nonischemic and ischemic into the cavernous sinus, the oculomotor
ing evidence and information, is needed manifestations of internal carotid artery (CN III), trochlear (CN IV), or abducens
to provide an optimum reasoned basis for dissection. (CN VI) nerves can be affected.29,69 The
the best decision. Thus, in the early stages of the pathol- 2 most likely mechanisms for these cra-
ogy, headache and/or cervical pain can be nial nerve palsies are (1) ischemia to the
FWjj[hdH[Ye]d_j_edWdZ the sole presentations of internal carotid nerve via the vasa nevorum (comparable
IocfjecWjebe]o artery dysfunction.42,54,63 <?=KH;( shows a to peripheral neurodynamic theory) and
With a history of stroke, an initial ques- typical pain distribution associated with (2) direct compression of the nerve axon
tion is whether or not the patient presents dissection of the internal carotid artery. by the enlarged vessel.3,29,69
at this point with signs and symptoms of The frontotemporal headaches are often Horner’s syndrome has been found
stroke, or impending stroke. The inter- described as cluster-like, thunder-clap, to be present in up to 82% of patients
nal carotid artery supplies the brain and migraine without aura, hemicrania con- with known internal carotid artery dis-
the retina. The natural onset and prog- tinua, or simply “different from previous section.10 Most commonly, this syndrome
ress of internal carotid artery dissection headaches.” The upper cervical or antero- occurs with head, neck, or facial pain.
begins with local arterial trauma, which, lateral neck pain, facial pain, and/or facial Carotid induced Horner’s syndrome
the presence of anhidrosis in postgangli- arteries was maintained through all po-
onic Horner’s syndrome. sitions of cervical movement. During this
In this second case report, the patient procedure, there was no reproduction of
describes longstanding symptoms that signs and symptoms indicative of either
do not relate to the classic pattern and hind-brain or internal carotid artery ter-
symptomatology of cervical vascular dis- ritory ischemia. As anticipated, cranial
ease. There were no subjective descrip- nerve examination revealed no remark-
tions of potential cranial nerve palsy. At able findings. Neuromusculoskeletal ex-
this stage, it was unlikely that the actual amination revealed a reliable relation of
present features were indicative of vascu- the patient’s pain to a specific stiff cer-
lar disease. vical joint complex, and local muscular
dysfunction.
Fh[Z_ifei_d]<WYjehiWdZFôi_YWb In summary, this patient, although
;nWc_dWj_ed presenting as apparently high risk for
This patient reported a significant his- cerebrovascular event, demonstrated

tory of cervical vascular and, specifically, patent flow in 4 vessels during cervical
internal carotid artery disease. This in it- movement, with no indication of tran-
self is considered evidence of poor cardio- sient brain ischemia. Her pain pattern
vascular status and a potential predictor was musculoskeletal in nature, and she
of future stroke. The patient had known did not present as classic vascular trauma
internal carotid artery occlusive disease. indicative of impending stroke. Although

It is reported that internal carotid artery there were obvious indicators of stroke
disease correlates to stroke, particularly risk (previous stroke, internal carotid ar-
<?=KH;)$Blood flow examination with handheld in younger patients with diabetes.15,35,45,46 tery disease), an informed decision could
ultrasound Doppler of (a) vertebral artery at the Although the patient presents as an ap- be made to reinstate manual therapy, sup-
suboccipital site, and (b) internal carotid artery at
parent high risk for adverse cerebro- ported by the fact the she derived great
the carotid sinus. The examination assesses velocity,
gkWb_jo"WdZfh[i[dY[%WXi[dY[e\XbeeZÔem_dW vascular event (internal carotid artery benefit from treatment. Manual therapy
specific vessel. The technique can be used to assess occlusion), her age and nondiabetic sta- in this case would be subject to a number
patency of flow during movement of the neck and head. tus may contribute towards lessening the of caveats: the avoidance of end-of-range
judgment on chance of stroke. movements known to stress the 4 cervical

manifests as a drooping eyelid (ptosis), As hypertension has been consistently vessels (primarily rotation and extension);
sunken eye (enophthalmia), a small and reported to be associated with cerebro- monitoring of new, unexpected signs and
constricted pupil (miosis), and facial vascular events (as mentioned earlier), symptoms indicative of vascular trauma;
dryness (anhidrosis), due to the overbal- blood pressure measurements were tak- reassessment of blood pressure and cra-
ance of parasympathetic activity in the en and found to be high. The patient re- nial nerve function if vascular trauma is
eye. The syndrome is a result of inter- ported much lower home readings. Blood suspected; communication and/or refer-
ruption to the sympathetic nerve fibers pressure monitoring is known to be influ- ral with vascular or neurology clinic in
supplying the eye. In the case of carotid enced by several factors,33 including the the event of any suspect symptomatology;
induced Horner’s syndrome, the pathol- immediate environment, and, although and emergency referral in event of acute
ogy is classified as postganglionic. The care was taken with the testing, this read- onset symptomatology. Medical refer-
superior cervical sympathetic ganglion ing could still be misleading. Ultrasound rals should be supported with objective
lies in the posterior wall of the carotid Doppler examination was undertaken to data from assessment procedures (blood
sheath, and the postganglionic fibers fol- assess the patency of all 4 vessels during pressure, cranial nerve examination, eye
low the course of the carotid artery before cervical spine movement (<?=KH;)). This examination).
making their way deep towards the eye examination technique has become a fo-
through the cavernous sinus. Compres- cus of interest for manual therapists in IKCC7HO
sion or ischemia as a result of internal recent years and may be considered as
carotid artery dysfunction will occur at a useful addition to physical examina-
J
his paper has presented contem-
the ganglion or distal to it. Some post- tion for patients with suspected vascular poraneous evidence and information
ganglionic sympathetic fibers that follow pathologies.64,66 regarding cervical arterial dysfunc-
the course of the external carotid artery In this case, observable flow in both tion and manual therapy. These 2 case
control facial sweating, accounting for internal carotid arteries and vertebral reports were used to illustrate how this
cal factors are major factors in this
Summary of Key Objective Examination
patient group61 and should, therefore,
J78B;* Procedures for Differentiating
be sensitive to the possible impact of
Vasculogenic Head and Neck Pain*
reinforcing biomedical beliefs about a
J[ij Fkhfei[ ;l_Z[dY[IjWjki B_c_jWj_ediWdZ7ZlWdjW][i chronic-pain episode.
Functional positional Affects flow in contralateral Poor sensitivity, variable EdboWii[ii[ifeij[h_ehY_hYkbW- 2. Develop increased awareness that
test, cervical rotation vertebral artery. Limited specificity. Blood flow studies tion. Results should be interpreted neck pain and headache may be pre-
effect on internal carotid support effect on vertebral with caution. Recommended by
artery. artery flow. existing protocols. Cannot predict
cursors to potential posterior circula-
propensity for injury. tion ischemia.
Functional positional Affects flow in internal ca- No specific diagnostic utility Primarily assesses anterior 3. Expand manual therapy theory to
test, cervical extension rotid arteries. Limited effect evidence available. Blood circulation. encompass the whole cervical vas-
on vertebral arteries. flow studies support effect on
internal carotid artery flow.
cular system, including the carotid
arteries.
Blood pressure Measure of cardiovascular Correlates to cervical arterial Reliability dependent on
examination health. atherosclerotic pathology. equipment, environment, and 4. Expand manual therapy theory and
experience. Continuous, not practice to include hemodynamic prin-

categorical, measure.
ciples and their relationship to move-
Cranial nerve Identifies specific cranial No specific diagnostic utility Reliability dependent on experiment anatomy and biomechanics.
examination nerve dysfunction resulting evidence available. ence.
from ischemia or vessel 5. Develop an awareness of the limita-
compression. tions of current objective tests and
Eye examination Assists in diagnosis of pos- No specific diagnostic utility Eye symptoms may be early enhance the knowledge that reliance
sible neural deficit related evidence available. warning of serious underlying on objective testing alone represents
to internal carotid artery pathology.
dysfunction. incomplete clinical reasoning.
Handheld Doppler Direct assessment of blood Limited manual therapy Reliability dependent on
6. Enhance subjective/objective ex-
ultrasound flow velocity. specific evidence. Existing equipment, environment, and amination by including vascular risk
studies suggest good to experience. factors such as hypertension and
[nY[bb[djh[b_WX_b_jo$LWb_Z_jo
requires further study. procedures such as cranial nerve and
simple eye examination.
*Reprinted from Manual Therapy, 11(4), Kerry and Taylor, Cervical arterial dysfunction assessment
and manual therapy, 243-253. Copyright 2006, with permission from Elsevier. 7. Consider new advances in the objec-
tive assessment of cervical arteries.
8. In cases of acute onset headache “un-

knowledge can be integrated into clinical decision making. J78B;* summarizes in- like any other,” conservative treatment
decision making. Case report 1 revealed formation on clinical utility for a number techniques are recommended in the
misdiagnosis in the presence of classic of the testing procedures referred to in early stages.
vertebral artery trauma. Closer attention this paper. 9. Where frank arterial injury is sus-
to the literature in this area would have Specifically, the following recommen- pected prior to or following treatment,
facilitated the clinician’s understanding dations, although not intended as defini- immediate triage to an appropriate
of vascular presentation and its relation- tive guidance, will assist advancement of emergency center is recommended,
ship to head and neck pain. Case report 2 practice and clinical reasoning based on together with a report on any treat-
demonstrated decision making informed the emerging evidence. T ment methods undertaken.
by knowledge of vascular dysfunction and
how treatment could be provided to a pa- H[Yecc[dZWj_edi
tient with known arterial disease. 1. Develop a high index of suspicion for H;<;H;D9;I
We acknowledge that these cases show cervical vascular pathology, particu-
'$ Allen CL, Bayraktutan U. Risk factors for ischae-
a divergence from classically taught ar- larly in cases of cervical trauma. Note mic stroke. Int J Stroke. (&&.1)0'&+#'',$^jjf0%%
terial pathology assessment (prema- that, although motor vehicle accident Zn$Ze_$eh]%'&$''''%`$'-*-#*/*/$(&&.$&&'.-$n
nipulative screening) and accept that has been reported as one of the most ($ Arnold C, Bourassa R, Langer T, Stoneham
the literature is used within a different common causes of CAD,6 as stated G. Doppler studies evaluating the effect of a
physical therapy screening protocol on vertebral
paradigm. We recommend that manual earlier, the actual prevalence of CAD
artery blood flow. Man Ther. 2004;9:13-21.
therapists involved in the assessment and posttrauma (although unknown) is )$ Arnold M, Bousser MG. Carotid and vertebral
management of cervical spine dysfunc- likely to be extremely low. The clini- artery dissection. Practical Neuro. 2005;5:100-
tion include what is known about cervical cian should be constantly aware that 109.
*$7hdebZC"8ekii[hC="<W^hd_="[jWb$L[hj[-
arterial dysfunction in their daily clinical chronic-pain issues and psychologi-
bral artery dissection: presenting findings and Grieve’s Modern Manual Therapy: The Vertebral math.2003.12.002
predictors of outcome. Stroke$(&&,1)-0(*//# Column. Edinburgh, UK: Churchill Livingstone; ))$CWdY_W=":[8WYa[h=":ec_d_YpWa7"[jWb$
(+&)$^jjf0%%Zn$Ze_$eh]%'&$'','%&'$ '//*0)-'#).&$ (&&-=k_Z[b_d[i\ehj^[cWdW][c[dje\Whj[h_Wb
IJH$&&&&(*&*/)$..*-)$)/ (&$ Grewal J, Anand S, Islam S, Lonn E. Prevalence hypertension: The Task Force for the Manage-
+$ Asavasopon S, Jankoski J, Godges JJ. Clinical and predictors of subclinical atherosclerosis ment of Arterial Hypertension of the European
diagnosis of vertebrobasilar insufficiency: resi- among asymptomatic “low risk” individuals Society of Hypertension (ESH) and of the Euro-
Z[djÊiYWi[fheXb[c$J Orthop Sports Phys Ther. in a multiethnic population. Atherosclerosis. pean Society of Cardiology (ESC). Eur Heart J.
(&&+1)+0,*+#,+&$^jjf0%%Zn$Ze_$eh]%'&$(+'/% (&&.1'/-0*)+#**($^jjf0%%Zn$Ze_$eh]%'&$'&',%`$ (&&-1(.0'*,(#'+),$^jjf0%%Zn$Ze_$eh]%'&$'&/)%
èifj$(&&+$'-)( Wj^[heiYb[hei_i$(&&-$&,$&(& [kh^[Whj`%[^c(),
,$ Beaudry M, Spence JD. Motor vehicle ac- ('$ Haldeman S, Kohlbeck FJ, McGregor M. Unpre- )*$CWddWc_J"8WXWI"E]WjW@$Fej[dj_Wbe\YWhej_Z
cidents: the most common cause of traumatic dictability of cerebrovascular ischemia associ- enlargement as a useful indicator affected by
vertebrobasilar ischemia. Can J Neurol Sci. ated with cervical spine manipulation therapy: high blood pressure in a large general popula-
2003;30:320-325. a review of sixty-four cases after cervical spine tion of a Japanese city: the Suita study. Stroke.
-$8_ekii[L":Ê7d]b[`Wd#9^Wj_bbed@"CWii_ek>" manipulation. Spine$(&&(1(-0*/#++$ 2000;31:2958-2965.
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.$9W]d_[8"8WhXW_n;"L_dYa;":Ê>[hZ[A"9Wc- (&&,1)'0).,#)/)$^jjf0%%Zn$Ze_$eh]%'&$'&',%`$ stenosis of the internal carotid artery]. Ter Arkh.
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^jjf0%%Zn$Ze_$eh]%'&$'&&-%i&&(-,#&&+#&&,&#' tion correlate with the severity of peripheral insufficiency? J Physiol. 2001;536P:S092.
/$9WfbWdBH"8_ekii[L$9[hl_YeYhWd_WbWhj[h_Wb arterial disease. Eur J Vasc Endovasc Surg. )-$C_jY^[bb@$L[hj[XhWbWhj[hoWj^[heiYb[hei_i0W
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305. ejvs.2005.11.022 Physiother Res Int. (&&(1-0'((#')+$
'&$9^Wd99"FW_d[C"EÊ:Wo@$9Whej_ZZ_ii[Yj_ed0
(*$AWmWcejeH"Jec_jW>"EaWO"E^jikaWD$7iie- ).$ Mitchell J, Keene D, Dyson C, Harvey L, Pruvey

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Cervical Arterial Dysfunction: Knowledge and Reasoning For Manual Physical Therapists

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[ CLINICAL COMMENTARY ]

ROGER KERRY, MSc, MMACP, MCSP¹7B7D@$J7OBEH"MSc, MCSP²