cervical artery dysfunction: implications for physiotherapy diagnosis and management
DESCRIPTION
Presentation on the diagnostic and management implications of cervical artery dysfunction in physiotherapy with specific attention to the role of manipulation and mobilization of the cervical spineTRANSCRIPT
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Cervical Artery Dysfunction (CAD):Cervical Artery Dysfunction (CAD):Implications for PhysiotherapyImplications for PhysiotherapyDiagnosis and ManagementDiagnosis and Management
Master Class Penticton, BC
September 13, 2010
Peter Huijbregts
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PresenterPresenter
Diploma Physiotherapy (1990)
MSc Manual Therapy (1994)
MHSc Physical Therapy (1997)
Doctor of Physical Therapy (2001)
Fellow Canadian Academy of ManipulativeTherapy, American Academy of OrthopaedicManual Therapy
Board-certified Orthopaedic Specialist
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PresenterPresenter
Assistant Professor, University of St.Augustine for Health Sciences
Advisory Faculty, NAIOMT
Editor-in-Chief, Consulting Editor JMMT
Clinical Consultant, ShelbournePhysiotherapy Clinic
Consulting Editor, Jones & BartlettPublishers
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ObjectivesObjectives
Upon completion of this session participants willbe able to discuss:
Epidemiology of cervical (vertebral andinternal carotid) artery dysfunction
Anatomy, pathology, and physiology relevantto cervical artery dysfunction
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ObjectivesObjectives
Research evidence on the use of manualtherapy interventions
Research linking cervical manual therapyinterventions to cervical artery dysfunction
Relevant clinical (differential) diagnosis
Risk management and emergencyprocedures related to cervical arterydysfunction
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HighHigh--profile cases in Canadaprofile cases in Canada
Laurie-Jean Mathiason
20-year old female
Fell down stairs and hurt her back
Boyfriend suggested seeing his chiropractor
Over the next months 189 adjustments in 21visits including upper cervical
Note: initial complaint was low back pain…
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HighHigh--profile cases in Canadaprofile cases in Canada
Rotary neck manipulation resulted ininability to turn head
That night she kept walking into thingsat work
Another visit to chiropractor next day
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HighHigh--profile cases in Canadaprofile cases in Canada
Neck adjustment
Patient immediately began to cry
Left eye rolled up, right roamedrandomly
Convulsions
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HighHigh--profile cases in Canadaprofile cases in Canada
Turned blue, foaming at the mouth, didnot recognize her mother
Coma
Died next day from a traumatic ruptureleft vertebral artery
Benedetti P, McPhail W. Spin Doctors 2002
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HighHigh--profile cases in Canadaprofile cases in Canada
Lana Dale Lewis, age 45, Toronto, ON
Treated for migraine
Complained of intense pain aftercervical manipulation
Stroke few days after visit
Second fatal stroke again a few dayslater on September 12, 1996
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HighHigh--profile cases in Canadaprofile cases in Canada
Inquest 2002-2004
Coroner’s jury verdict: Death byaccident
Linked stroke causally to manipulation
Burdett J. Fatal chiropractic: The Lana Dale Lewis case. Association for Science &Reason 2007
Laeeque H, Boon H. Print media coverage on the Lana Dale Lewis Inquest verdict:Exaggerated claims or accurate reporting? Health Law Review 13(1):7-15.
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HighHigh--profile cases in Canadaprofile cases in Canada
Mrs. Sandy Nette, Edmonton, AB
Bilateral vertebral artery dissection
Chiropractic neck manipulation
$ 500-million class-action lawsuit againstchiropractor, his clinic, Alberta College andAssociation of Chiropractors, and AB Ministryof Health and Wellness
Benedetti P, McPhail W. Twist and Shout. Globe and Mail, June 14, 2008
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Relevance to PhysiotherapyRelevance to Physiotherapy
Now wait a minute…
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Relevance to PhysiotherapyRelevance to Physiotherapy
Now wait a minute…
Why would we as physiotherapists beworried about the association betweenmanipulation and stroke?
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Relevance to PhysiotherapyRelevance to Physiotherapy
Now wait a minute…
Why would we as physiotherapists beworried about the association betweenmanipulation and stroke?
Isn’t this purely a chiropractic problem?
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Clinical VignetteClinical Vignette
63-year old male
Hypertensive
Right cerebral infarct five years earlier
Four months previously vertebrobasilarinfarct
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Clinical VignetteClinical Vignette
PHYSIOTHERAPIST applied cervicalmanipulation
Immediate dizziness post-manipulation
Over the next few hours dysarthria,dysphagia, and left-sided paralysis
Medullary infarct
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Situation in the NetherlandsSituation in the Netherlands
In 2006, patients lodged 18 complaintswith professional association
Of these 5 pertained to complaintsresulting from manual therapyinterventions to the neck
Vossen H. De Wijer A. Cervicale manipulaties: risico’s, neveneffecten enprognostische factoren. Waar liggen onze verantwoordelijkheden?Tijdschr Man Ther 2007;4:36-37.
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Epidemiology CADEpidemiology CAD
1-2% of patients with blunt, non-penetratingheadtrauma
Includes facial and skull base fractures andtraumatic brain injury
Increased incidence of ICA dissection inpatients with thoracic injuries
Increased incidence of vertebral arterydissection in patients with cervical fracturesand cord lesions
Debette S, Leys D. Cervical artery dissections: Predisposing factors, diagnosis, andoutcome. Lancet Neurol 2009;8:668-678.
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Epidemiology CADEpidemiology CAD
North American general populationstudy: 1-year incidence 2.6 (95% CI1.86-3.33) per 100,000 for CAD
Dijon, France: 1-year incidence 2.9 per100,000 for ICA dissection
Lee VH, Brown RD, Mandrekar JN, Mokri B. Incidence and outcome of cervicalartery dissection: a population-based study. Neurology 2006; 67:1809–1812.
Debette S, Leys D. Cervical artery dissections: Predisposing factors, diagnosis, andoutcome. Lancet Neurol 2009;8:668-678.
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Epidemiology CADEpidemiology CAD
1-year incidence dissection vertebralartery 0.97 (95% CI 0.52-1.4)
Almost half of incidence ICA dissection:1.72 (95% CI 1.13-2.32) per 100,000
Lee VH, Brown RD, Mandrekar JN, Mokri B. Incidence and outcome of cervicalartery dissection: a population-based study. Neurology 2006; 67:1809–1812.
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Epidemiology CADEpidemiology CAD
Of all CAD, 20% develop into CVA
CAD accounts for approximately 20% ofall strokes in young versus 2.5% inolder patients
Blunt SB, Galton C. Cervical carotid or vertebral artery dissection. BMJ1997;314:243.
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Epidemiology CADEpidemiology CAD
Note the extremely low incidence ofCAD and even lower incidence of CAD-associated CVA in the generalpopulation
Remember this when establishingpretest probability
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Anatomy and physiologyAnatomy and physiologyreviewreview
Time to review some material?
1. Arterial anatomy
2. Mechanisms of arterial injury
3. Anatomy and physiology of thecervical arteries
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Anatomy: ArteryAnatomy: Artery
Three-layer structureartery
Intima
Media
Adventitia
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Anatomy: ArteryAnatomy: Artery
INTIMA
Layer of endothelial cells lining vessel interior
Rests on basal lamina
Turnover rate 1% per day
Sub-endothelial layer: longitudinally arrangedloose connective tissue and some smoothmuscle cells
In arteries: Internal elastic lamina, fenestratedelastin allows diffusion to vessel wall
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Anatomy: ArteryAnatomy: Artery
MEDIA
Concentric layers of helically arrangedsmooth muscle cells
Variable amounts of elastic fibers andlamellae, reticular fibers, andproteoglycans
In larger arteries: External elastic laminaseparating media from adventitia
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Anatomy: ArteryAnatomy: Artery
ADVENTITIA
Longitudinally oriented Type I collagenand elastic fibers
Gradually becomes continuous withenveloping connective tissue
Junqueira LC, et al. Basic Histology. 8th ed (1995)
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Mechanisms of ArterialMechanisms of ArterialTraumaTrauma
Subintimal hematoma
Intimal tear
Intimal tear with thrombus formation
Intimal tear with embolic formation
Vessel wall dissection with subintimalhematoma
Vessel wall dissection with pseudo-aneurysm
False aneurysm
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Subintimal HematomaSubintimal Hematoma
Disruption vasavasorum leads tosubintimal bleedingand occlusion of VAlumen
May also causevasospasm
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Intimal TearIntimal Tear
Intima is the leastelastic layer and,therefore, most likely totear
Exposure sub-endothelial layer causesthrombosis
Clot may propagateproximally or distally
Vasospasm due tothrombin release
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Intimal Tear with EmbolizationIntimal Tear with Embolization
Propagating clotextends into lumenand breaks off
Embolus
Distal arterialocclusion andinfarction
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Dissection and SubintimalDissection and SubintimalHematomaHematoma
Disruption intima andinternal elastic lamina
Blood dissects theselayers from muscularmedia: dissectinganeurysm
Compresses lumen
Exposure sub-endothelial tissue andthrombosis
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Dissection and SubintimalDissection and SubintimalHematoma: ReperfusionHematoma: Reperfusion
Hemorrhage mayagain rupturethrough intima
Reestablishescommunication withtrue lumen
Recanalization mayoccur
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Dissection with PseudoDissection with Pseudo--AneurysmAneurysm
Disruption of media,internal elastic lamina,and intima
Pseudo-aneurysmunder extendingadventitia
May propagate distally
Frequent cause ofocclusion PICA
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False AneurysmFalse Aneurysm
Disruption total arterialwall
Peri-arterialhemorrhage containedin fascia
External compressionlumen
Turbulence in lumenmay cause thrombusand embolus formation
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Anatomy: Vertebral ArteryAnatomy: Vertebral Artery
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V1: ExtraV1: Extra--Vertebral SegmentVertebral Segment
Branches off the subclavian artery and entersthe transverse foramen of C6 in 89% ofpeople
Enters C7 in 3%, C5 in 6%, and C4 in 1% ofpopulation
Anterior boundary formed by anterior scaleneand longus colli muscles
Posterior boundary transverse processes C7-T1 and first rib
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V2: IntraV2: Intra--Vertebral SegmentVertebral Segment
Runs through transverse foramina C7-C2
Bordered anteromedially byuncovertebral joints
May be adherent to periosteum of theuncinate processes
Many anatomical variants have beendescribed
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V3: AtlantoV3: Atlanto--Axial SegmentAxial Segment
Transverse foramen of C1 is far lateral ascompared to that of C2
This causes a dorsolateral routing of thevertebral artery from the C2 to the C1transverse foramen
Tethered at C1 and C2 transverse foraminaand atlanto-axial membrane
Artery more prone to injury at this segment?
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AtlantoAtlanto--Axial Segment andAxial Segment andRotationRotation
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V3: AtlantoV3: Atlanto--Axial SegmentAxial Segment
After exiting the C1 transverse foramen theartery runs medially in a sulcus in the lateralmass of the atlas
Anatomical variant: Arcuate foramen andponticulus posterior in posterior arch atlas
Anterior boundary is formed by the C0-C1joint
Posterior boundary is formed by the obliquuscapitis superior and rectus capitis posteriormajor muscles
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V4: Subforaminal and IntraV4: Subforaminal and Intra--CranialCranial SegmentSegment
Pierces the posterior atlanto-occipitalmembrane and dura and arachnoidmater
Courses on intra-cranially insubarachnoid space
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Cervical BranchesCervical Branches
Spinal rami branch off the vertebral arteryand enter the intervertebral foramen wherethey split in anterior and posterior radiculararteries, anterior central artery, and anteriorand posterior vertebral canal arteries
Radicular arteries supply the anterior andposterior nerve roots and spinal ganglion
The other branches supply epidural tissues
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Cervical BranchesCervical Branches
Muscular, cutaneous, and articular ramisupply the local joints, intrinsic cervicalmuscles, and the skin innervated by thedorsal ramus of the cervical spinal nerves
These branches also supply the flaval andinterspinal ligaments
The ascending axial arteries supply the bodyand odontoid process of C2 and the alar,transverse, and cruciform ligaments
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SubSub--Foraminal BranchesForaminal Branches
Subforaminal branches include the anterior,posterior, and lateral spinal arteries
The posterior spinal artery also frequently branchesoff from the posterior inferior cerebellar artery
Below C4 these spinal arteries form anastosmoseswith the spinal rami of the vertebral arteries throughthe anterior radicular arteries
This leaves the upper cervical cord vulnerable tovascular ischaemia: Implication?
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IntraIntra--Cranial BranchesCranial Branches
The posterior inferior cerebellar artery (PICA)branches off before coalescence of thevertebral arteries into the basilar artery
PICA supplies the dorsolateral medullaoblongata, the cerebellar vermis, and anumber of cerebellar nuclei
The basilar artery supplies the medullaoblongata, the pons, the mesencephalon, andparts of the cerebellum
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IntraIntra--Cranial BranchesCranial Branches
The labyrinthine arteries branch off early fromthe basilar artery or the anterior inferiorcerebellar arteries, which makes thevestibular nucleus and the inner ears verysusceptible to ischaemic abnormalities
The posterior cerebral arteries branch off thebasilar artery and supply the thalamus andhypothalamus and the occipital and temporallobes
Oostendorp R. Functionele Vertebrobasilaire Insufficientie. PhD Thesis. Nijmegen,The Netherlands: Katholieke Universiteit Nijmegen, 1988.
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Anatomy: Internal carotidAnatomy: Internal carotidarteryarteryFig 2
C6
C1 (atlas)
Vertebral ArteryInternal Carotid Artery
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Anatomy: ICAAnatomy: ICA
Provides 80% of blood flow to the brainversus 20% supplied by thevertebrobasilar system
Traverses sternocleidomastoid, longuscapitis, stylohyoid, omohyoid, anddigastric muscles
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Anatomy: ICAAnatomy: ICA
Fixed to the anterior aspect of the C1vertebral body and in the carotid canalin the petrous bone
Sustained rotation and extension-rotation tests have also been proposedas tests of ICA function
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Relevance to Physiotherapy?Relevance to Physiotherapy?
Physiotherapists routinely use cervical manualtherapy in patients with:
Neck pain
Headache: Cervicogenic, tension-type,migraine
Dizziness: Cervicogenic
TMD
Subacromial impingement
Lateral epicondylalgia
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Do these patients make up aDo these patients make up abig portion of our daybig portion of our day--toto--dayday
clinical practice?clinical practice?
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Epidemiology Neck PainEpidemiology Neck Pain
• Point prevalence neck pain: 9%
• 6-month prevalence: 54%
• Lifetime prevalence: 66%
• Point prevalence chronic neck pain (>6months): 18%
Douglass AB, Bope ET. Evaluation and treatment of posterior neck pain infamily practice. J Am Board Fam Pract 2004;17:S13-S22.
Guez M, et al. Chronic neck pain of traumatic and non-traumatic origin.Acta Orthop Scand 2003;74:576-579
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Epidemiology HeadacheEpidemiology Headache
Cervicogenic headache: 0.4-2.5% in thegeneral population and up to 15-20% in thosewith chronic headaches
Tension-type headache: Two-thirds of malesand over 80% of females in developedcountries
Migraine headache: 1-year prevalence 6-8%in males and 15-18% of females in Europeand US
World Health Organization. Headache Fact Sheet. 2008.
Haldeman S, Dagenais S. Cervicogenic headaches: A critical review.Spine J 2001;1:31-46
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Epidemiology DizzinessEpidemiology Dizziness
Dizziness accounts for 7% of physician visitsfor patients over the age of 45
For adults over 65, it is the number onereason to visit a physician
Approximately 15 to 30% of peopleexperiencing dizziness will seek medicalattention
Huijbregts P, Vidal P. Dizziness in orthopaedic physical therapy practice:
Classification and pathophysiology. J Man Manip Ther 2004; 12: 196-211
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Epidemiology impingementEpidemiology impingement
Point-prevalence in the Dutch generalpopulation of 20.9%
1-year incidence of 11.2 per 1,000 patients inDutch general medical practice
41% of the patients seeking care forshoulder complaints diagnosed withimpingement
Picavet HSJ, Van Gils HWV, Schouten JSAG. Klachten van het bewegingsapparaat in deNederlandse bevolking: Prevalenties, consequenties en risicogroepen. Centraal Bureauvoor Statistiek, Bilthoven: 2000
Van der Windt DA, Koes BW, De Jong BA, Bouter LM. Shoulder disorders in generalpractice: Incidence, patient characteristics and management. Ann Rheum Dis 1995;54:959-964
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Epidemiology lateralEpidemiology lateralepicondylalgiaepicondylalgia
Affects 1-2% of general population
Allander E. Prevalence, incidence, and remission rates of some common rheumaticdiseases and syndromes. Scand J Rheumatol 1974;3(3):145-153.
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Relevance to Physiotherapy?Relevance to Physiotherapy?
Cervical spine diagnoses were the reason forreferral in 16% of 1,258 outpatient PTpatients, second only to lumbar spine-relateddiagnoses
Headache reported as co-morbidity in 22% of2,433 patients presenting for outpatientPT/OT
Boissonnault WG. Prevalence of comorbid conditions, surgeries,and medication use in a physical therapy outpatient population:A multi-centered study. J Orthop Sports Phys Ther 1999;29:506-519
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Relevance to Physiotherapy?Relevance to Physiotherapy?
11% of 1,258 PT patients indicated theshoulder as their chief area ofcomplaints
Boissonnault WG. Prevalence of comorbid conditions, surgeries, andmedications in a physical therapy outpatient population: A multi-centered study.J Orthop Sports Phys Ther 1999;29:506-525
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Relevance to Physiotherapy?Relevance to Physiotherapy?
All member organizations IFOMT teachcervical segmental examination,manipulation, and mobilizationtechniques
19/20 member organizations teachupper cervical manipulation
Rivett D, Carlesso L. Safe Manipulative Practice in the Cervical Spine (2008)
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So why use manual therapy?So why use manual therapy?
Evidence-based practice
The process of integrating the bestresearch evidence available with bothclinical expertise and patients’ values
Sackett DL, et al. Evidence-Based Medicine. How to Practice & Teach EBM. NewYork, NY: Churchill Livingstone, 1997.
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So why use manual therapy?So why use manual therapy?
Evidence-informed not evidence-drivenpractice
The clinician takes the evidence fromresearch into account when making clinicaldecisions with regard to patient managementbut evidence does not dictate these decisions
Bohart A. Evidence-based psychotherapy means evidence-informed, not evidence-driven. Journal of Contemporary Psychotherapy 2005;35:39-53.
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Research evidenceResearch evidence
Systematic reviews on the effectiveness ofmanual therapy for patients with mechanicalneck pain have indicated positive outcomeson pain and function for (non) thrustinterventions but only when combined withexercise and only in subacute and chronicconditions
Gross AR, Hoving JLK, Haines TA, et al: A Cochrane Review of manipulation andmobilization for mechanical neck disorders. Spine 29:1541,2004.
Sarigiovannis P, Hollins B: Effectiveness of manual therapy in the treatment ofnon-specific neck pain: A review. Phys Ther Rev 10:35,2005.
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Research evidenceResearch evidence
Hoving et al reported no significant between-groupdifferences for pain, perceived recovery, and functionin patients with neck pain managed by their familyphysician, exercise and stretching, or non-thrusttechniques and stabilization exercises at 1 year
But indicating relevant short-term effectiveness theynoted significantly better results for the manualtherapy group at 7 weeks
Hoving JL, De Vet HCW, Koes BW, et al: Manual therapy, physical therapy, orcontinued care by the general practitioner for patients with neck pain: Long-termresults from a pragmatic randomized controlled clinical trial. Clin J Pain22:370,2006.
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Research evidenceResearch evidence
Further indicating the cost-effectiveness ofmanual therapy management for patients withmechanical neck pain, an economicevaluation alongside this randomized trial(RCT) also showed significantly lower cost forthe manual therapy intervention as comparedto both others
Korthals-De Bos IBC, Hoving JL, Van Tulder MW: Cost effectiveness ofphysiotherapy, manual therapy, and general practitioner care for neck pain:Economic evaluation alongside a randomised controlled trial. BMJ326:911,2003.
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Research evidenceResearch evidence
Multi-center RCT on patients with cervicalradiculopathy
True versus sham mechanical traction forcervical radiculopathy
Both groups also received cervical andthoracic non-thrust techniques, thoracic thrusttechniques, postural education, and cervicalmobility and cervical and scapulothoracicstrengthening exercises
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Research evidenceResearch evidence
No between-group differences
Within-group statistically and clinicallysignificant improvements in pain andfunction
Young IA, Michener LA, Cleland JA, Aguilera AJ, Snyder AR: Manualtherapy, exercise, and traction for patients with cervical radiculopathy:
A randomized clinical trial. Phys Ther 89:632,2009.
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Research evidenceResearch evidence
A systematic review of randomized and(non) controlled clinical trials foundconsistent significant improvements withsoft tissue, non-thrust, and thrustinterventions for patients withcervicogenic dizziness
Reid SA, Rivett DA: Manual therapy treatment of cervicogenic dizziness: Asystematic review. Man Ther 10:4,2005
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Research evidenceResearch evidence
RCT in patients with cervicogenic dizzinesstreated with a Mulligan cervical SNAGintervention showed clinically and statisticallysignificant reduced dizziness, neck pain, anddizziness-related disability over the grouptreated with detuned laser
Reid SA, Rivett DA, Katekar MG, Callister R: Sustained natural apophyseal glides
are an effective treatment for cervicogenic dizziness. Man Ther 13:357,2008
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Research evidenceResearch evidence
A systematic review noted moderateevidence for short-term efficacy ofspinal manipulation similar toAmitryptiline in patients with migraineand chronic tension-type headache
No added benefit if manipulation wasadded to massage in patients withepisodic tension-type headache
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Research evidenceResearch evidence
Moderate evidence that spinalmanipulation was more efficacious forcervicogenic headache than massage
Bronfort G, Assendelft WJJ, Evenas R, Haas M, Bouter L: Efficacy of
spinal manipulation for chronic headache: A systematic review. J
Manipulative Physiol Ther 24:457,2001
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Research evidenceResearch evidence
A systematic review yielded two RCTsthat showed significant effects of spinalthrust interventions on headacheintensity and duration and medicationintake in patients with cervicogenicheadache
Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Pareja JA:Spinal manipulative therapy in the management of cervicogenic
headache. Headache 45:1260,2005
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Research evidenceResearch evidence
RCT showed that twice weekly 45-minutemassage and trigger point release sessionsresulted in significant decreases in headachefrequency, intensity, and duration andheadache-related disability in patients withtension-type headache with these effectslasting into the 3-week follow-up period
Moraska A, Chandler C: Changes in clinical parameters in patients withtension-type headache following massage therapy: A pilot study. J Man
Manip Ther 16:106,2008
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Research evidenceResearch evidence
Prospective cohort study in patients with migraineshowed significant improvements in headachefrequency, intensity, duration, and disability after 2months of thrust interventions as deemed indicatedby the clinician to the whole spine
At 12 months there were still significantimprovements as compared to baseline for headachefrequency, intensity, and duration and medication use
Tuchin PJ: A twelve month clinical trial of chiropractic spinal manipulative therapy for
migraine. Aust Chiro Ost 8:61,1999
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Research evidenceResearch evidence
RCT comparing spinal manipulation tointerferential current in patients with migraine
Significant between-group differencesfavoring manipulation for headachefrequency, duration, disability, and medicationuse during the 2-month post-interventionfollow-up
Tuchin PJ, Pollard H, Bonello R: A randomized controlled trial ofchiropractic spinal manipulative therapy for migraine. J Manipulative
Physiol Ther 23:91,2000
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Research evidenceResearch evidence
Kalamir et al reported that cervicalmanipulation might be beneficial forpatients with temporomandibulardisorders, although thisrecommendation was based solely oncase studies
Kalamir A, Pollard H, Vitiello AL, Bonello R: Manual therapy fortemporomandibular disorders: A review of the literature. J Bodywork
Movement Ther 11:84,2007
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Research evidenceResearch evidence
Cohort studies on patients with subacromialimpingement
Medium and long-term (up to one year) benefits ofthrust and non-thrust interventions to the cervical andthoracic spine, ribs, shoulder, and shoulder girdle
Over or in addition to exercise, medical care, andsteroid infiltration
Bang MD, Deyle GD: 2000 Comparison of supervised exercise with and without manual physicaltherapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther30:126,2000
Bergman GJD, Winters JC, Groenier KH, Pool JJM, Meyboom-De Jong B, Postema K, Van derHeijden GJMG: Manipulative therapy in addition to usual medical care for patients withshoulder dysfunction and pain. Ann Int Med 141:432,2004
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Research evidenceResearch evidence
Vicenzino et al have provided preliminarysuggestions for a treatment-based classificationsystem for patients with lateral epicondylalgia
Perhaps patients presenting with greater pressurepain threshold deficits relative to pain-free grip forcedeficits should first be treated with manipulativetherapy techniques directed at the cervical spine
Vicenzino B, Cleland JA, Bisset L: Joint manipulation in the management of lateralepicondylalgia: A clinical commentary. J Man Manip Ther 15:50,2007
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Clinical decisionClinical decision--makingmaking
Evidence for effectiveness
Evidence for risk of harm
Risk-benefit analysis
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Risk of harm researchRisk of harm research
Standardization of terminology only justbeginning
Minor adverse events: relatively shortduration, less severe, occur immediatelyafter treatment or with short latencyperiod, minimal effect on function, fullyreversible, require no adaptation ofcurrent treatment or additional treatment
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Risk of harm researchRisk of harm research
Major adverse events: moderate to longduration, moderate to severe andunacceptable, require additional intervention
Carlesso L, MacDermid JC, Santaguida PL. Standardization of adverse eventterminology and reporting in orthopaedic physical therapy: application to thecervical spine. J Orthop Sports Phys Ther 2010;40:455-463.
Carnes D, Mullinger B, Underwood M. Defining adverse events in manualtherapies: A modified Delphi consensus study. Man Ther 2010;15:2-6.
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Risk of harm researchRisk of harm research
Research into risk of harm is wrought withmethodological shortcomings
Obvious ethical concerns with studies thatwould prospectively expose patients to asuspected risk factor
Non-standardized terminology
Non-adherence to CONSORT guideline
Mostly based on case reports and caseseries
Emphasizes serious adverse events
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Minor adverse eventsMinor adverse events
Survey South-African physiotherapists
Mostly dizziness and headache
Also nystagmus, vision disturbances, nauseaand vomiting, acute wry neck, increased armpain +/- neurological deficit, syncope
Average duration 6.3 days
1 minor event per 3,020 manipulationsMichaeli A. Reported occurrence and nature of complications following manipulative
physiotherapy in South Africa. Aust J Physiother 1993;39:309-315.
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Minor adverse eventsMinor adverse events
Survey Irish manual physiotherapists
26% respondents reported adverse eventsafter cervical manipulation/mobilization inpreceding 2 years
Mostly dizziness, nausea, and temporaryincrease in complaints
1 case each of drop attack, syncope, and TIApost-mobilization
Sweeney A, Doody C. Manual therapy for the cervical spine and reported adverseeffects: A survey of Irish manipulative physiotherapists. Man Ther 2010;15:32-36.
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Minor adverse eventsMinor adverse events
Prospective study physiotherapists, osteopaths,chiropractors
60.9% of 283 patiënten reported at least one post-manipulation minor event
Headache (19.8%), stiiffness (19.5%), localdiscomfort (15.2%), radiating discomfort (12.1%), andfatigue (12.1%)
Muscle tension (5.8%), dizziness (4.3%) en nausea(2.7%)
Majority of complaints occurred within 4 hours andhad resolved fully within 24 hours
Cagnie B, Vinck E, Beernaert A, Cambier D. How frequent are side effects of spinal
manipulation and can these side effects be predicted? Man Ther 2004;9:151-6.
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Minor adverse eventsMinor adverse events
RCT comparing chiropractic cervicalmanipulation to mobilization
85 of 280 patients reported advesreevent
Manipulation group: 48 patients with120 complaints
Mobilization group: 37 patients with 92complaints
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Minor adverse eventsMinor adverse events
25% increased neck pain and stiffness
Headache (15.7%), fatigue (10%), radiating pain(6.1%)
Dizziness, extremity weakness, tinnitus, depressionor anxiety, nausea and vomiting, vision disturbances,confusion, or disorientation (1%)
Majority occurred within 24 hours and fully resolvedwithin 24 hours of onset
Headache, dizziness, fatigue, and nausea in up to75% general population in preceding three days
Hurwitz EL, Morgenstern H, Vassilaki M, Chiang LM. frequency and clinical predictors of adversereactions to chiropractic care in the UCLA Neck Pain study. Spine 2005; 30:1477-1484.
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Minor adverse eventsMinor adverse events
Systematic review
No increase in neck pain for cervical manipulation ascompared to cervical mobilization (combined withthoracic manipulation): relative risk (RR) =1.25, 95%CI 0.84-1.87; P > 0.05)
Small increase in incidence of mild neurologicalsymptoms: RR = 1.96, 95% CI 1.09-3.54, P < 0.05).
Carlesso LC, Gross AR, Santaguida PL, Burnie S, Voth S, Sadie J. Adverse events associatedwith the use of cervical manipulation and mobilization for the treatment of neck pain inadults: A systematic review. Man Ther 2010;15(5):434-444.
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Major adverse eventsMajor adverse events
“…The temporal relationship between younghealthy patients without osseous or vasculardisease who attend an SMT practitioner andthen suffer these rare strokes is so welldocumented as to be beyond reasonabledoubt indicating a possible causalrelationship…”
Terrett AGJ. Vertebrobasilar stroke following spinal manipulation therapy.In: Murphy R. Conservative Management of Cervical Spine Syndromes(2000)
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Serious ManipulationSerious Manipulation--RelatedRelatedAdverse EventsAdverse Events
Two types of vertebral arterystroke:
1. Wallenberg syndrome
2. Locked-in syndrome
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Wallenberg SyndromeWallenberg Syndrome
Dorsolateral medullary syndrome ofWallenberg
Occlusion PICA
Other cause: Occlusion parent vertebralartery, a.k.a. syndrome of BabinskiNageotte
Due to destruction nuclei and pathwaysin dorsolateral medulla oblongata
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Wallenberg SyndromeWallenberg Syndrome
Inferior cerebellar peduncle: ipsilateral ataxiaand hypotonia
Descending spinal tract and nucleus CN V:loss of pain and temperature sensationipsilateral face and loss corneal reflex
Ascending lateral spinothalamic tract: loss ofpain and temperature sensation contralateraltrunk and limbs (alternating analgesia)
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Wallenberg SyndromeWallenberg Syndrome
Descending sympathetic tract:Ipsilateral Horner’s syndrome
Lower vestibular nuclei: Nystagmus,vertigo, nausea, and vomiting
Nucleus ambiguous ofglossopharyngeal and vagus nerves:Hoarseness, dysphagia, or intractablehiccups
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LockedLocked--In SyndromeIn Syndrome
Cerebromedullospinal disconnectionsyndrome
Occlusion mid-basilar artery
Bilateral ventral pontine infraction
Effectively transects brain stem at mid-pons region
Patients are “conscious, paralyzedmutes”
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LockedLocked--In SyndromeIn Syndrome
Consciousness retained becausereticular formation midbrain and rostralpons is unaffected
Cerebrospinal tracts destroyed:Decerebrate rigidity
Nuclei CN V-XII destroyed: Also affectsoculomotor nerve (CN III) due todescending neuronal connections
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LockedLocked--In SyndromeIn Syndrome
Cutaneous sensation may be grossly intactbecause lateral spinothalamic tract locatedlaterally in brain stem is spared
Auditory nerves ascend brainstem lateral toinfarct area: Patient still can hear
CN IV spared: Eye convergence and upwardgaze intact
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Establishing causalityEstablishing causality
Retrospectively establishing cause-and-effect relationships?
In clinical medicine we cannot establishcausal relationship beyond any doubt
But we can increase or decreaseconviction of a causal effect
Bradford-Hill criteria: Sir Austin BradfordHill (1965)
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BradfordBradford--Hill Criteria forHill Criteria forCausationCausation
Biologically plausible
Proposed cause temporally related tooccurrence
Consistent across different samples andgroups
Positive correlation exposure andoccurrence
No other explanation
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BradfordBradford--Hill Criterion # 1:Hill Criterion # 1:Biological PlausibilityBiological Plausibility
It is certainly biologically plausible thatexcessive mechanical force imparted to
the artery could cause arterial walldamage especially in case of
pathologically weakened artery
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BradfordBradford--Hill Criterion # 1:Hill Criterion # 1:Biological PlausibilityBiological Plausibility
Cadaver study: 5 cadavers 80-99 y.o.
SMT contralateral C1-C2, C3-C4, C6-C7
AROM and extension-rotation testing
6.2% +/-1.3% to the distal (C0-C1) loopof the VA and a 2.1% +/-0.4% strain tothe proximal (C6-subclavian artery) loop
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BradfordBradford--Hill Criterion # 1:Hill Criterion # 1:Biological PlausibilityBiological Plausibility
Strain range AROM tests: 1.2+/-0.6% -12.5+/-10.1%
Strain range extension-rotation tests: 3.2+/-2.4% - 11.8+/-8.6%
Failure testing: 139% to 162%
Single thrust unlikely to mechanically disruptVA
Symons B, Leonard TR, Herzog W. Internal forces sustained by the vertebral artery
during spinal manipulative therapy. J Manipulative Physiol Ther 2002;25:504-10.
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BradfordBradford--Hill Criterion # 1:Hill Criterion # 1:Biological PlausibilityBiological Plausibility
24 test specimens from cadaveric rabbitascending aorta
Specimens were exposed to 1000 straincycles of 0.06 and 0.30 of their in situ length
Control and 0.06 strain tissues werestatistically the same (P = .406)
0.30 strain group showed micro-structuraldamage beyond that seen in the controlgroup (P = .024)
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BradfordBradford--Hill Criterion # 1:Hill Criterion # 1:Biological PlausibilityBiological Plausibility
Cadaveric rabbit arterial tissue similar in sizeand mechanical properties of that of thehuman VA can withstand repeat strains ofmagnitudes and rates similar to thosemeasured in the cadaveric VA during cervicalSMT without incurring micro-structuraldamage beyond control levels
Austin N, DiFrancesco LM, Herzog W. Micro-structural damage in arterial tissueexposed to repeated tensile strains. J Manipulative Physiol Ther 2010;33:14-19
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BradfordBradford--Hill Criterion # 1:Hill Criterion # 1:Biological PlausibilityBiological Plausibility
Eight piezoelectric ultrasound crystals of 0.5-mm diameter were sutured into the lumen ofthe left and right VA of one cadaver
Strains calculated during cervical spinalrange of motion testing, chiropractic cervicalspinal manipulation adjustments, andvertebrobasilar insufficiency testing
Lateral flexion + rotation and lateral flexionSMT at C2-C3 and C4-C5 bilaterally
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BradfordBradford--Hill Criterion # 1:Hill Criterion # 1:Biological PlausibilityBiological Plausibility
Complex and non-intuitive strain patterns ofthe VA within the cervical transverse foramina
Strains for cervical spinal manipulations wereconsistently lower than those obtained forcervical rotation
Neck manipulations impart stretches on theVA that are well within the normal physiologicrange of neck motion
Wuest S, Symons B, Leonard T, Herzog W. Preliminary report: biomechanics ofvertebral artery segments C1-C6 during cervical spinal manipulation. JManipulative Physiol Ther 2010;33:273-278.
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BradfordBradford--Hill Criteria #2Hill Criteria #2 -- #3#3
Proposed cause temporally related tooccurrence
Consistent across different samples andgroups
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Evidence Linking ManipulationEvidence Linking Manipulationto Stroketo Stroke
Terrett (1995): Narrative review ofEnglish, French, German,Scandinavian, and Asian literature1934-2000: 185 cases reported, deathin 30 cases
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Evidence Linking ManipulationEvidence Linking Manipulationto Stroketo Stroke
Updated in 2001: 236 cases reported
Triano and Kawchuk (2006) updatedthis review and found reports of 80additional cases of post-manipulationcomplications
Triano JJ, Kawchuk G. Current Concepts in SpinalManipulation and Cervical Arterial Incidents (2006)
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Evidence Linking ManipulationEvidence Linking Manipulationto Stroketo Stroke
DiFabio (1999): systematic review overperiod 1925-1997
177 cases with mostly arterial dissection orspasm, brain stem lesion, and Wallenbergsyndrome
Death resulted in 18% (n=32)
Also visual defects, hearing loss, balancedeficits, and phrenic nerve damage
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Evidence Linking ManipulationEvidence Linking Manipulationto Stroketo Stroke
Cervical manipulation NOT a new treatmentin 41% of patients
When described rotational thrust seemedmost injurious (23%)
However, technique described in only 54%
DiFabio RP. Manipulation of the cervical spine: Risks and benefits.Phys Ther 1999;79:50-65
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Evidence Linking ManipulationEvidence Linking Manipulationto Stroketo Stroke
Ernst (2002): Systematic review over 1995-2001 period
42 cases with serious adverse events: Mainlyarterial dissection
Also long thoracic nerve palsy, diskherniations, myelopathy, epidural hematoma
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Evidence Linking ManipulationEvidence Linking Manipulationto Stroketo Stroke
Insufficient data on type of manipulation used
Underreporting bias?
Ernst E. Manipulation of the cervical spine: A systematicreview of case reports of serious adverse events,1995-2001. Med J Aust 2002;176:376-380
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Evidence Linking ManipulationEvidence Linking Manipulationto Stroketo Stroke
True risk remains unknown
Estimated risks adjusted assuming areporting rate of only 10% in literature
All complications: 5-10 per 10 million
Serious complications: 6 in 10 million
Risk of death: 3 in 10 million
Hurwitz EL, et al. Manipulation and mobilization of the cervicalspine: A systematic review of the literature. Spine1996;21:1746-1759
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Current Emphasis on ICA:Current Emphasis on ICA:Let’s Put This in PerspectiveLet’s Put This in Perspective
Terrett only found five cases (2.7%) of185 reported cervical artery injuries
associated with SMT involving the ICA
Terrett AGJ. Current Concepts: Vertebrobasilar Complicationsfollowing Spinal Manipulation (2001)
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Current Emphasis on ICA:Current Emphasis on ICA:Let’s Put This in PerspectiveLet’s Put This in Perspective
Systematic review Medline 1966-2000
13 reports of dissection ICA temporallyassociated with neck manipulation
Risk of ICA dissection with manipulationestimated at less than 1 in 601 million
Haneline MT, Croft AC, Frishberg BM. Association of internal carotid arterydissection and chiropractic manipulation. The Neurologist 2003;9:35-44
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Bradford Hill criterion #4:Bradford Hill criterion #4: PositivePositivecorrelation exposure and occurrencecorrelation exposure and occurrence
582 cases of vertebrobasilar accidents (VBA)in ON, 1993-1998
Age and sex-matched controls from provincialinsurance database
Exposure to chiropractic using provincialinsurance data
VBA< 45 years old 5 times more likely (95%CI 1.31-43.87) to have visited a chiropractorwithin 1 week before VBA
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Bradford Hill criterion #4:Bradford Hill criterion #4: PositivePositivecorrelation exposure and occurrencecorrelation exposure and occurrence
Also, in younger age group 5 times as likelyto have had ≥ 3 visits with cervical diagnosisin month before VBA (95% CI 1.34-18.57)
No significant associations for those over 45years old
Further prospective study indicated; sourcesof bias acknowledged
Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation andstroke: A population-based case control study. Stroke
2001;32:1054-1060
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Bradford Hill criterion #4:Bradford Hill criterion #4: PositivePositivecorrelation exposure and occurrencecorrelation exposure and occurrence
Population-based study over period 1993-2001
818 subjects with VBA stroke
Case crossover portion: 4 control periodsrandomly chosen from the year before thestroke
Case control portion: 4 age and sex-matchedcontrols from provincial insurance database
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Bradford Hill criterion #4:Bradford Hill criterion #4: PositivePositivecorrelation exposure and occurrencecorrelation exposure and occurrence
Case control study
Visiting chiropractor in month beforestroke
> 45: OR 0.83 (95% CI: 0.52-1.32)
< 45: OR 3.13 (95% CI: 1.48-6.63)
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Bradford Hill criterion #4:Bradford Hill criterion #4: PositivePositivecorrelation exposure and occurrencecorrelation exposure and occurrence
However,…
Case control study
Visiting GP in month before stroke
> 45: OR 2.67 (95% CI: 2.25-3.17)
< 45: OR 3.57 (95% CI: 2.17-5.86)
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Bradford Hill criterion #4:Bradford Hill criterion #4: PositivePositivecorrelation exposure and occurrencecorrelation exposure and occurrence
“… [A similar association between chiropracticand GP visits in the month before the stroke
event] suggests that patients withundiagnosed VA dissection are seekingclinical care for headache and neck pain
before having a VBA stroke…”
Cassidy JD, et al. Risk of vertebrobasilar stroke and chiropracticcare. Spine 2008;33:S176-S183.
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Bradford Hill criterion #5: No otherBradford Hill criterion #5: No otherexplanationexplanation
Are there other plausible causes orpathologies that might lead to CAD?
Risk factor identification: Role in clinicaldiagnosis
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Risk FactorsRisk FactorsAtherosclerosis
Hypertension
Hypercholesterolaemia
Hyperlipidaemia
Hyperhomocysteinaemia
Diabetes mellitus
Genetic clotting disorders
Infections
Smoking
Free radicals
Upper cervical instability
Migraine
Direct vessel trauma
Autosomal polycystickidney disease
Iatrogenic causes
Endothelial inflammatorydisease (e.g., temporalarteriitis)
Arteriopathies
Age
Female gender
Thyroid disease
Oral contraceptive use
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Direct Vessel Trauma:Direct Vessel Trauma:
Manipulation
Whiplash
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Direct Vessel Trauma:Direct Vessel Trauma:WhiplashWhiplash
In a retrospective analysis, Beaudry andSpence attributed 70 of 80 traumaticallyinduced cases of vertebrobasilarischaemia to motor-vehicle accidents
Beaudry M, Spence JD. Motor vehicle accidents: The mostcommon cause of traumatic vertebrobasilar ischaemia. Can J
Neurol Sci 2003;30:320-325
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Whiplash and DizzinessWhiplash and Dizziness
Dizziness, vertigo, and dysequilibrium aresymptoms in 20-58% of individuals thathave sustained a whiplash-type injury of
the cervical spine or a closed headinjury
Wrisley DM, et al. Cervicogenic dizziness: A review ofdiagnosis and treatment. J Orthop Sports Phys Ther2000;30:755-766
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Whiplash and DizzinessWhiplash and Dizziness Damaged peripheral labyrinth or cochlea in 90% and
both in 69% of 227 post-whiplash patients atneurology evaluation
92% met the diagnostic criteria for inner earcontusion
Of this subgroup, 63% was diagnosed with BPPV,64% with secondary endolymphatic hydrops, and21% with unilateral or bilateral perilymphatic fistulae
25% prevalence of BPPV in 273 consecutive patientswith rear-end impact whiplash injury without headinjury
Grimm RJ. Inner ear injuries in whiplash. J Whiplash Rel Disord 2002:1:65-75;Oostendorp RAB, et al. Dizziness following whiplash injury: A neuro-otologicalstudy in manual therapy practice and therapeutic implication. J ManualManipulative Ther 1999;7:123-130
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Not all Dizziness Implies CADNot all Dizziness Implies CAD
Benign Paroxysmal Positional Vertigo
Cervicogenic dizziness
Vertebrobasilar insufficiency
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Dizziness type Nystagmus and dizzinesscharacteristics
Associated signs andsymptoms
Cervicogenicdizziness
Positioning-type No latency period Brief duration Fatigable with
repeated motion
Nystagmus Neck pain Suboccipital
headaches Cervical motion
abnormality onexamination
BPPV Positioning-type Short latency: 1-5seconds
Brief duration: <30seconds
Fatigable withrepeated motion
Nystagmus
Cervicalarterydysfunction
Positional-type Long latency: 55+/-18 seconds
Increasingsymptoms and signswith maintainedhead position
Not fatigable withrepeated motion
Ischaemic and(depending on etiology)possibly non-ischaemicsigns and symptoms asdescribed in Table 10
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HallpikeHallpike--Dix ManeuverDix Maneuver
Positionalnystagmus on thistest has been shownto identify patientswith posterior SCCBPPV with 78%sensitivity
Specificity as highas 88% has beenreported
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Age: 30Age: 30--45 year old?45 year old?
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AgeAge
Relevant to the clinical diagnosis ofspontaneous if not manipulation-induced CAD is that Lee et al (2006)reported a mean age of 45.8 years forNorth-American patients
Lee VH, Brown RD, Mandrekar JN, Mokri B. Incidence and outcome ofcervical artery dissection: a population-based study. Neurology 2006;
67:1809–1812
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AgeAge
In Europe, Touzé et al (2003) reported amean age of 44.0 and Arnold et al(2006) noted a mean age of 45.3 yearsfor patients diagnosed with CAD
Touzé E, Gauvrit JY, Moulin T, Meder JF, Bracard S, Mas JL. Risk ofstroke and recurrent dissection after a cervical artery dissection: amulti-center study. Neurol 2003;61:1347–1351.
Arnold M, Kappeler L, Georgiadis D, et al. Gender differences inspontaneous cervical artery dissection. Neurol 2006; 67:1050–1052.
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Gender: FemaleGender: FemalePredisposition?Predisposition?
Terrett (1995) literature review of 185 patientswith severe CSMT complications
Gender known for 180
77 males (42.8%) of whom 13 died (16.9%)
103 females (57.2%) of whom 17 died(16.5%)
Reflects of male-female ratio in chiropracticoffice: 40.7-59.3% or 44.8-55.2%?
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GenderGender
In three large studies (Beletsky et al2003, Lee et al 2006, Schievink et al1994) 50-52% of patients with CADwere women
In two European studies (Arnold et al2006, Touzé et al 2003) 53-57% weremen
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GenderGender
ICA dissection seems to be more common inmen and at an older age (47.0 versus 43.4years) than is VA dissection (Dziewas et al2003, Lee et al 2006)
Beletsky V, Nadareishvili Z, Lynch J, Shuaib A, Woolfenden A, Norris JW. Cervicalarterial dissection: Time for a therapeutic trial? Stroke 2003;34:2856-2860.
Schievink WI, Mokri B, O’Fallon WM. Recurrent spontaneous cervical-arterydissection. N Engl J Med 1994;330:393–397.
Dziewas R, Konrad C, Drager B, et al. Cervical artery dissection: Clinical features,risk factors, therapy and outcome in 126 patients. J Neurol 2003;250:1179-1184.
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ArteriopathiesArteriopathies
Marfan syndrome
Ehlers-Danlos syndrome
Fibromuscular dysplasia
Cystic medial necrosis
Osteogenesis imperfecta
Alpha-1-antitrypsin deficiency
Autosomal dominant polycystic kidneydisease
Previous CAD
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Marfan SyndromeMarfan Syndrome
Higher reported incidence of CAD
Typically show signs of impaired skeletalintegrity resulting in joint hypermobility
Extremely arched palate with crowded teeth
Long limbs, spider-like fingers:Arachnodactyly
Chest abnormalities: Pectus excavatum
Kyphoscoliosis
Sometimes only vascular defects withminimal or no outward clinical manifestations
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EhlersEhlers--Danlos SyndromeDanlos Syndrome
Higher reported incidence of CAD
Vascular Type IV variant may play a role infamilial CAD
History of easy bruising
Thin skin with visible veins
Characteristic facial features: Protrudingeyes, small chin, thin nose and lips, andsunken cheeks
Martin JJ, et al. Familial cervical artery dissections: Clinical,
morphologic, and genetic studies. Stroke 2006;37:2924-2929
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Hypermobility: Beighton ScoreHypermobility: Beighton Score
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Hypermobility: Brighton CriteriaHypermobility: Brighton Criteria
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Fibromuscular DysplasiaFibromuscular Dysplasia
Rare non-atherosclerotic and non-inflammatory vascular condition
Primarily affects medium-sized arteries,in particular the ICA and renal arteries
Present in females 3 to 4 times morefrequently than in males
Bilateral in 65% of patients
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Fibromuscular DysplasiaFibromuscular Dysplasia
May be related to mechanical stress to thearterial wall, ischaemia within the vessel dueto disturbance of the vasa vasorum, orhormonal activity that negatively affects themuscular wall
Present in up to 23% of patients with ICAdissection
Presenting complaint may vary from TIA toheadache and dizziness
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Cystic Medial NecrosisCystic Medial Necrosis
Focal degeneration of the elastic tissueand muscle of the tunica media, with thedevelopment of mucoid material
Associated with a variety of systemicdisorders
Typically occurs in patients > 40
Male: female ratio = 2:1
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Cystic Medial NecrosisCystic Medial Necrosis
Typically affects large arteries, chieflythe aorta
Sometimes associated with the cervicalarteries
Breakdown of collagen, elastin, andsmooth muscle, along with an increasein the artery’s ground substance
Ehlers-Danlos and Marfan syndrome
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Osteogenesis ImperfectaOsteogenesis Imperfecta
Bone fragility
Also blue sclerae, diminished hearing,thinness of the skin, and jointhypermobility
Type 1 associated with CAD:Decreased or structurally defective typeI collagen produced
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AlphaAlpha--11--Antitrypsin DeficiencyAntitrypsin Deficiency
• Circulating serine proteinase inhibitor ofproteolytic enzymes that contributes tomaintenance of integrity of connective tissues
• Deficiency provides insufficient protectionagainst effect collagenase and elastase andmay damage vessel wall
• Genetic systemic disorder with lung and liverdisease
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AlphaAlpha--11--Antitrypsin DeficiencyAntitrypsin Deficiency
• 22 consecutive patients with SCAD and 113controls with non-CAD stroke
• Significantly lower levels in CAD (P=0.01)
• OR 17.7 (95% CI: 2.9-105.6) for A1-AT levels< 90 mg/dl
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AlphaAlpha--11--Antitrypsin DeficiencyAntitrypsin Deficiency
Findings were refuted by a more recent andmethodologically sound study
Another small study consisting of 12 spontaneousCAD patients found 3 cases with a deficiency ofalpha-1-antitrypsin
Overall, there is little evidence in support of thisrelationship
Vila N, et al. Levels of α1-antitrypsin in plasma and risk of spontaneouscervical artery dissections. Stroke 2003;34:e168-169
Haneline M, Lewkovich GN. A narrative review of pathophysiologicalmechanisms associated with cervical artery dissection. J Can Chiropr
Assoc 2007; 51(3):146–157
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Autosomal DominantAutosomal DominantPolycystic Kidney DiseasePolycystic Kidney Disease
Common heritable condition: Prevalence rateof 1 in 400 to 1 in 1000
Affecting the renal system
May also lead to extra-renal complications,including connective tissues disorders
Haneline M, Lewkovich GN. A narrative review ofpathophysiological mechanisms associated with cervical artery
dissection. J Can Chiropr Assoc 2007; 51(3):146–157
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Previous CADPrevious CAD
Incidence of new CAD in first year post-CAD:1.7% (95% CI 0.3-3.6%)
Cumulative 1-year incidence of 10.7% (95%CI 6.5-14.9%) and 3-year incidence of 14.0%(95% CI 8.9-19.1%) for new CVA post initialCAD diagnosis
Weimar C, Kraywinkel K, Hagemeister C, Haass A, Katsarava Z, Brunner F, et al.Recurrent stroke after cervical artery dissection. J Neurol Neurosurg Psychiatry2010;81:869-873.
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Cardiovascular Risk FactorsCardiovascular Risk Factors
Hypertension
Tobacco use
Hypercholesterolaemia
Diabetes
Atherosclerosis
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HypertensionHypertension
Risk factors studied: tobacco use,hypertension, diabetes, andhypercholesterolaemia
Compared a group of 153 consecutivepatients with CAD, a group of patientswith ischaemic stroke unrelated to CAD,and a group of controls
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HypertensionHypertension
Hypertension was the only one of 4variables significantly associated withCAD, but only in the subgroup of CADpatients who developed cerebralinfarction
Overall OR 1.94 (95% CI: 1.01-3.70)
For VA dissection OR 2.69 (95%CI:1.20-6.04)
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AtherosclerosisAtherosclerosis
362 cadaver vertebral arteries
Grade 0 (0% occlusion) to grade 5 (75%occlusion) atherosclerosis
Highest incidence of grade of atherosclerosis:Grade 3
Mainly in atlanto-occipital portion of VA: 4.0%
Also in intra-cranial portion of VA: 35.2%
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AtherosclerosisAtherosclerosis
Blood flow proportional to fourth powerof diameter
Population at risk for developing VBI?
Note: Only basic science extrapolation!
Mitchell J. Vertebral artery atherosclerosis: A risk factor in the use
of manipulative therapy? Physiother Res Int 2002;7:122-13
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HypercholesterolaemiaHypercholesterolaemia
Prospective study on infection as risk factorfor CAD
47 consecutive patients with spontaneousCAD and 52 with ischemic stroke
Significantly higher hypercholesterolaemia incontrols (42.6%) versus subjects (12.9%)
Guillon B, et al. Infection and the risk of spontaneous cervical artery
dissection. Stroke 2003;34:e79-e81
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HypercholesterolaemiaHypercholesterolaemia
72 CAD patients compared with 72 non-CAD stroke control patients
Diabetes, current smoking,hypercholesterolaemia, and oralcontraceptive use not associated withCAD
Pezzini A, et al. History of migraine and the risk of spontaneouscervical artery dissection. Cephalagia 2005;25:575-580
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HypercholesterolaemiaHypercholesterolaemia
So: Hypercholesterolaemia isprotective?
Comparing apples and oranges…
Hypercholesterolaemia more frequent insubgroup of CAD patients withischaemic events
Arnold M, et al. Vertebral artery dissection: Presenting findings andpredictors of outcome. Stroke 2006;37:2499-2503
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Thyroid diseaseThyroid disease
Case-control study involving 58 subjects
Present in 31.0% of CAD patients (9/29),compared with 6.9% of non-CAD strokepatients (2/29) (P=0.041)
Immunologic mechanisms contributing to thevascular damage?
Reports of ICA dissection in patients withGraves disease: Effects of thyroid hormoneson the smooth muscle cells and endotheliumof the vascular system
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Clinical VignetteClinical Vignette
39-year old male
Felt dizzy and clammy
Consulted osteopath and receivedtraction manipulation
Semi-comatose state and vomiting
Died in hospital 19 hours later
Cerebellopontine infarction followingbilateral vertebral artery dissection
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InfectionInfection Seasonal variation incidence of CAD: related
to the higher incidence of upper respiratoryinfections during the winter?
31.3% (95% CI: 26.5-36.4) of cohort of 352CAD patients developed dissection in thewinter
Statistically significantly more than in thespring, 25.5% (95% CI: 21.1-30.3), thesummer 23.5% (95% CI: 19.3-28.3), and theautumn 19.7% (95% CI: 15.7-24.1)
Paciaroni M, et al. Seasonal variability in spontaneous cervical artery dissection. JNeurol Neurosurg Psychiatry 2006;77:677-679
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InfectionInfection
• Prospective study on infection as risk factor for CAD
• 47 consecutive patients with spontaneous CAD and52 with ischemic stroke
• Acute infection present within 4 weeks precedingvascular event more common in SCAD (31.9%) thancontrol subjects (13.5%)
• Crude OR 3.0 (95% CI: 1.1-8.2, P= 0.032)
• Adjusted OR 3.1 (95% CI: 1.1-9.2)
Guillon B, et al. Infection and the risk of spontaneous cervical arterydissection. Stroke 2003;34:e79-e81
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Oral Contraceptive UseOral Contraceptive Use
One retrospective case-control study(17subjects, 24 controls) investigatingCAD risk factors generated statisticallysignificant findings
Current (but not past) use of oralcontraceptives associated with CAD
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Oral Contraceptive UseOral Contraceptive Use
Another case-control study that explored CADrisk factors found that 58.3% of CAD caseswere using oral contraceptives (27 of 47), ascompared with 40.0% of the controls who hadischemic stroke from another cause (21 of52): non-significant difference
No consensus
Haneline M, Lewkovich GN. A narrative review ofpathophysiological mechanisms associated with cervical arterydissection. J Can Chiropr Assoc 2007; 51(3):146–157
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Other Risk FactorsOther Risk Factors
Mechanical stress of coughing, sneezing, orvomiting: OR 1.6 (95% CI: 0.67-3.80)
Vascular risk factors OR 0.14 (95% CI: 0.34-0.65)
Current smoking habit OR 0.49 (95% CI:0.18-1.05)
Triano JJ, Kawchuk G. Current Concepts in Spinal Manipulationand Cervical Arterial Incidents (2006)
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Systematic Review of RiskSystematic Review of RiskFactors CADFactors CAD
Systematic review risk factors cervicalartery dissection
Two computerized databases, 1966-2005
31 case control studies
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Systematic Review of RiskSystematic Review of RiskFactors CADFactors CAD
Aortic root diameter > 34 (mm):OR=14.2 (95% CI: 3.2-63.6)
Homocysteine levels (may causeendothelial damage): OR=1.3 (95% CI:1.05-1.52)
Little relevance to PT clinical practice…
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Systematic Review of RiskSystematic Review of RiskFactors CADFactors CAD
More relevant to PT clinical practice:
Migraine: OR=3.6 (95% CI: 1.5-8.6)
Trivial trauma (neck manipulation): OR=3.8(95% CI: 1.3-11)
Recent infection: OR=1.6 (95% CI: 0.67-3.80)
However, most studies had major sources ofbias
Rubinstein SM, et al. A systematic review of the risk factors for cervical artery
dissection. Stroke 2005;36:1575-1580
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Bradford Hill criteriaBradford Hill criteria
Although opinions certainly and justifiablydiffer, case reports and narrative reviews ofsuch case reports provided by authors indiverse geographical locations temporallylinking possible mechanical trauma of thecervical arteries due to manipulation to CADwould seem to qualify as supporting the firstthree criteria
However, we can argue criteria 4 and 5 arenot satisfied…
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Clinical DiagnosisClinical Diagnosis
Two relevant questions…
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First Relevant QuestionFirst Relevant Question
How do we identify patients at riskfor cervical artery dysfunction?
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Identify patients at risk forIdentify patients at risk forCADCAD
Clinically relevant risk factors: Previousmedical history of treatment with cervicalmanual therapy interventions, hypertension,previous infection, previous CAD, andmigraine headache
Questionable risk factors: Atherosclerosis,thyroid disease, and arteriopathies…
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Second Relevant QuestionSecond Relevant Question
How do we identify patients with cervicalartery dysfunction in progress?
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They are not all this easy…They are not all this easy…
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Presenting Complaint?Presenting Complaint?
Major presenting complaint of 137patients who subsequently had an SMT-induced vertebrobasilar vascularincident
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Presenting ComplaintPresenting Complaint
47.4%: Neck pain and stiffness
19.7%: Neck pain, stiffness, and headache
16.8%: Torticollis
2.2%: Low back pain
2.2%: Abdominal complaint
1.5%: (Kypho) scoliosis
1.5%: Head cold
1.5%: Upper thoracic pain
0.7%: Upper limb numbness
0.7%: Hay fever
Terrett AGJ. Vertebrobasilar stroke following spinal manipulation therapy. In: Murphy R.Conservative Management of Cervical Spine Syndromes (2000)
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So Where Does This LeaveSo Where Does This LeaveUs?Us?
Presenting complaint provides norelevant information
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Physical Examination?Physical Examination?
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De KleynDe Kleyn--Nieuwenhuyse TestNieuwenhuyse Test
In 1927, De Kleyn and Nieuwenhuysereported decreased or even absentvertebral artery blood flow based oncadaver perfusion studies in differenthead and neck positions
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De KleynDe Kleyn--Nieuwenhuyse TestNieuwenhuyse Test
Based on these anatomical observations andthese early perfusion studies, the sustainedextension-rotation and the sustained rotationtests have been proposed and widelyinstructed and used as tests to determine thepresence of vertebrobasilar artery dysfunction
De Kleyn A, Nieuwenhuyse AC. Schwindelanfälle und Nystagmusbei einer bestimmten Stellung des Kopfes. ActaOtolaryngologica 1927;11:155-157
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Sustained ExtensionSustained Extension--RotationRotationTest and VATest and VA
Extensively studied with equivocal results
Some authors have reported significantdecreases in VA blood flow, whereas otherstudies found no changes
Case reports have noted false negativeresults
Case series have reported 75-100% falsepositive results
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Sustained Rotation Test andSustained Rotation Test andVAVA
Research findings for the sustainedcervical rotation test are equallyequivocal
Significant decreases or no effect notedon vertebral artery blood flow or volume
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Sustained ExtensionSustained Extension--RotationRotationTest and VATest and VA
Meta-analysis of Doppler studies of VA bloodflow velocity
Effect size: Cohen’s d
VA blood flow velocity compromised more inpatients than asymptomatic subjects, oncontralateral rotation, in sitting more thanlying, intra-cranial more than cervical
Mitchell J. Vertebral artery blood flow velocity changes with cervical spine rotation: A meta-analysis of the evidence with implications for professional practice. J Manual ManipulativeTher 2009;17:46-57.
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Sustained (Extension)Sustained (Extension)Rotation Test and ICARotation Test and ICA
Refshauge noted an increase in rightICA blood flow velocity with sustainedcontralateral rotation in healthyvolunteers
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Sustained (Extension)Sustained (Extension)Rotation Test and ICARotation Test and ICA
In contrast, Licht et al found no change inpeak flow or time-averaged mean flowvelocity in the ICA during sustainedextension-rotation test
Patients nonetheless experienced symptoms(vertigo, visual blurring, nausea, hemicranialparaesthesiae) classically considered apositive response on this test
Licht PB, Christensen HW, Høilund-Carlsen PF. Carotid arteryblood flow during premanipulative testing. J ManipulativePhysiol Ther 2002;25:568-572.
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Sustained (Extension)Sustained (Extension)Rotation Test and ICARotation Test and ICA
Rivett et al reported increase in ICA bloodflow velocity with cervical extension due tonarrowing in the ICA?
Decrease in peak systolic and end-diastolicblood flow velocity in both ICA duringsustained rotation
Found no between-group differences forsubjects that were positive or negative on thistest
Rivett DA, Sharpless KJ, Milburn PD. Effect of premanipulative tests onvertebral artery and internal carotid artery blood flow: A pilot study. JManipulative Physiol Ther 1999;22:368-375.
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Psychometric DataPsychometric Data
Duplex Doppler ultrasonography
Measured blood flow and vessel diameter
Subjects 1,108 consecutive subjects referredfor neurovascular evaluation
136 (12.3%) had unexplained vertebrobasilardistribution symptoms
Extension-rotation position held for at least 10seconds
Sakaguchi M, et al. Mechanical compression of the extracranial
vertebral artery during neck rotation. Neurol 2003;61:845-847
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Psychometric DataPsychometric Data
Richter and Reinking calculateddiagnostic accuracy statistics
Comparing signs and symptoms withextension rotation as clinical test andUS findings as reference test
Richter RR, Reinking MF. Evidence in Practice. Phys Ther2005;85:589-599
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Psychometric DataPsychometric Data
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Psychometric DataPsychometric Data
Sensitivity 9.3% (95% CI: 4-19.9%)
Specificity 97.8% (95% CI: 96.7-98.5%)
LR+ 4.243 (95% CI: 1.678-10.729)
LR- 0.928 (95% CI: 0.851-1.011)
Interpretation in light of extremely lowpretest probability?
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Psychometric DataPsychometric Data
12 experimental and 30 control subjectsrecruited from chiropractic clinics
Experimental group had history of symptomsrelated to head and neck movement andpositive Wallenberg test (head and neckextension-rotation for 30 seconds)
Non-vascular causes excluded byradiography and neurologist examination
Côté P, et al. The validity of the extension-rotation test as a clinical screeningprocedure before neck manipulation: A secondary analysis. J ManipulativePhysiol Ther 1996;19:159-164
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Psychometric DataPsychometric Data
Extension-rotation test held for 30 seconds
Doppler ultrasound at C3-C5: Systolic peakvelocity to end-diastolic minimum velocity
Positive index test: Vertigo, nausea, tinnitus,lightheadedness, visual problems, numbnessof the face or one side of the body,nystagmus, vomiting, or loss ofconsciousness
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Psychometric DataPsychometric Data
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Predictive ValidityPredictive Validity
How can positional testing ofhaemodynamics in a still patent vesselbe expected to produce clinically usefulinformation regarding the risk of injurywith manipulative interventions?
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Predictive ValidityPredictive Validity
With an already pathologically weakenedvessel wall, performing the test itself mightput the patient at greater risk due to thepotential stretching forces exerted
At least in cadaver studies, strain valuesproduced during the test exceeded thoseproduced with manipulation
Thiel H, Rix G. Is it time to stop functional pre-manipulation testing
of the cervical spine? Man Ther 2005;10:154-158
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Predictive ValidityPredictive Validity
Haldeman et al did a retrospective analysis of64 medicolegal records describingcerebrovascular ischaemia after cervical SMT
The clinicians involved described doing thesustained extension-rotation test in 27 cases
None of these patients had adverseresponses
Haldeman S, et al. Unpredictability of cerebrovascular ischaemia associated withcervical spine manipulation therapy: A review of sixty-four cases after cervicalspine manipulation. Spine 2002;27:49-55
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Again, Where Does ThisAgain, Where Does ThisLeave Us?Leave Us?
We talked about the limited value of:
Presenting complaint
Clinically relevant risk factors
Questionable risk factors
Sustained extension-rotation test would atthe very most only seem relevant whenpositive
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Teaching Provocative TestsTeaching Provocative Tests
17/20 member organizations IFOMTteach provocative tests involvingrotation +/- extension
In March 2004, clinic directors of all USchiropractic colleges agreed to abandonteaching provocative tests
Rivett D, Carlesso L. Safe Manipulative Practice in the Cervical Spine (2008)
Clum G. Cervical Spine Adjusting and the Vertebral Artery (2006)
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Remember the Two RelevantRemember the Two RelevantQuestions?Questions?
Goals of history and examination
Screen patients at risk for adverseeffect with intervention
Identify patients with cervical arterydysfunction in progress?
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FiveFive DDss AAnd Threend Three NNss Dizziness
Drop attacks
Diplopia (including amaurosis fugax and cornealreflux)
Dysarthria
Dysphagia (including hoarseness and hiccups)
Ataxia of gait
Nausea
Numbness (in ipsilateral face and/or contralateralbody)
Nystagmus
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NystagmusNystagmus
Repetitive, back-and-forth, involuntaryeye movements initiated by slow driftsaway from the visual target
Pendular nystagmus consists of slowsinusoidal oscillations
Jerk nystagmus is characterized by analternating slow drift and a quickcorrective phase
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NystagmusNystagmus
Spontaneous nystagmus may imply anacute peripheral vestibular lesion andmay occur in the symptom-free intervalin patients with vestibular migraine
Jerk nystagmus with the quick phaseindicating the unaffected side
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NystagmusNystagmus
Purely vertical (upbeat or downbeat) ortorsional spontaneous nystagmus isindicative of a central vestibular lesion
Nystagmus due to a central lesionusually cannot be suppressed withvisual fixation
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NystagmusNystagmus
Positional downbeat vertical or skewnystagmus: Posterior fossa lesions(Arnold-Chiari malformation or anothercompressive lesion at the foramenmagnum)
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NystagmusNystagmus
Pendular nystagmus occurs mostcommonly in patients with multiplesclerosis and brain stem stroke
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Cervical Artery DysfunctionCervical Artery Dysfunction
Non-ischaemic signs and symptoms
Ischaemic signs and symptoms
Vertebrobasilar system
Internal carotid artery
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NonNon--Ischaemic Signs andIschaemic Signs andSymptoms VASymptoms VA
Ipsilateral posterior neck pain
Ipsilateral occipital headache
Sudden-onset and severe
Described as stabbing, pulsating, aching,“thunderclap”, sharp, or of an unusualcharacter
“A headache unlike any ever experiencedbefore…”
Rarely C5-C6 nerve root impairment due tolocal neural ischaemia
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Ischaemic Signs andIschaemic Signs andSymptoms VASymptoms VA
Five Ds And 3 Ns
Vomiting
Loss of short-term memory
Vagueness
Hypotonia and limb weakness affecting armor leg
Anhydrosis: lack of facial sweating
Hearing disturbances
Horner syndrome
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Ischaemic Signs andIschaemic Signs andSymptoms VASymptoms VA
Malaise
Perioral dysaesthesia
Photophobia
Clumsiness
Agitation
Cranial nerve palsies
Hindbrain stroke: Wallenberg or locked-insyndrome
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NonNon--Ischaemic Signs andIschaemic Signs andSymptoms ICASymptoms ICA
Ipsilateral upper and mid-cervical pain
Ipsilateral fronto-temporal or peri-orbitalheadache
Sudden onset, severe, uncommoncharacter
Horner syndrome
Pulsatile tinnitus
Cranial nerve palsies
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NonNon--Ischaemic Signs andIschaemic Signs andSymptoms ICASymptoms ICA
Ipsilateral carotid bruit
Neck swelling
Scalp tenderness
Anhydrosis face
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Ischaemic Signs andIschaemic Signs andSymptoms ICASymptoms ICA
TIA
Middle cerebral artery distribution stroke
Retinal infarction
Amaurosis fugax: Temporary blindness
Local patchy blurring of vision: Scintillatingscotomata
Weakness extra-ocular muscles
Protrusion eye
Swelling eye or conjunctiva
Horner syndrome
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Carotid BruitCarotid Bruit
56% sensitivity and 91% specificity fordetection of a 70-99% carotid stenosis whencompared with color duplex ultrasound
Implication: Maybe this is a test we need todo more often when the index of suspicion israised?
Magyar MT, et al. Carotid artery auscultation:Anachronism or useful screening procedure? NeurolRes 2002;24:705-708
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Cranial Nerve PalsiesCranial Nerve Palsies
Relevant to the physical examination are thecranial nerve palsies that may occur withcervical artery dissection
Dissection of the ICA mainly causes CN IX-XII dysfunction with the hypoglossal nerveinitially affected and then the other threenerves; eventually all cranial nerves exceptthe olfactory can be affected
Cranial nerve palsies are part of theischaemic presentation of a vertebral arterydissection
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Cranial Nerve PalsiesCranial Nerve Palsies
Large study of hospitalized patientswith CAD
Only 7% had cranial nerve palsies
Debette S, Leys D. Cervical artery dissections: Predisposing factors, diagnosis, andoutcome. Lancet Neurol 2009;8:668-678.
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Cranial Nerve PalsiesCranial Nerve Palsies
Cranial nerve Test L/RI. Olfactory Identify different odors + -II. Optic Test visual fields (Confrontation method) + -III. Oculomotor Upward, downward, and medial gaze + -IV. Trochlear Downward and lateral gaze + -V. Trigeminal Corneal reflex, face sensation, clench teeth + -VI. Abducens Lateral gaze + -VII. Facial Close eyes tight, smile, whistle, puff cheeks + -VIII. Vestibulo-cochlear Hear watch ticking, hearing tests, balance tests + -IX. Glossopharyngeal Gag reflex, ability to swallow + -X. Vagus Gag reflex, ability to swallow, say “Ahhh” + -XI. Accessory Resisted shoulder shrug + -XII. Hypoglossal Tongue protrusion (Observe for deviation) + -
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Horner SyndromeHorner Syndrome
Four physical signs: miosis, ptosis,enophthalmos, and anhydrosis
Miosis or inability to dilate a pupil
Paralysis of the dilatator pupillae muscle
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Horner SyndromeHorner Syndrome
Incomplete ptosis or droopy upper eyelid
Weakness tarsalis superior muscle
Ptosis can occur due to weakness in thelevator palpebrae, a voluntary muscleinnervated by the oculomotor nerve or as aresult of weakness in the sympatheticallyinnervated tarsalis superior muscle
Ptosis can also occur congenitally, and it canoccur as a familial condition, with increasingage, fatigue, depression, and drowsiness
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Horner SyndromeHorner Syndrome
Enophthalmus or deeper-seated eye
Weakness orbitalis muscle
Anhydrosis or decreased sweating
Affects ipsilateral head and shoulders
Syndrome often incomplete
Especially the enophthalmus and theanhydrosis are frequently absent
Miosis is often only noticeable in a darkenvironment when the unaffected pupildilates and the affected pupil does not
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Horner SyndromeHorner Syndrome
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Horner SyndromeHorner Syndrome
Three possible locations for the lesion:
The central neuron runs from thehypothalamus to the ciliospinal center and islocated in the cervical spinal cord (C8-T2)
This may occur as a result of ischaemicprocesses affecting the medulla (i.e.,vertebrobasilar ischaemia) or as a result ofinsult to the spinal cord
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Horner SyndromeHorner Syndrome
The secondary neurons run from theciliospinal center by way of the nerveroots C8-T2 to the sympathetic gangliaand through these ganglia to thesuperior cervical or stellate ganglion
This may occur as a result of, e.g.,syringomyelia or a tumor of the apex ofthe lung
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Horner SyndromeHorner Syndrome
The tertiary neuron runs from the stellateganglion to the dilatator pupillae and thevascular supply to the iris
This may occur due to carotid ischaemia
Clinical implications?
Note: A congenital form of Horner’s syndromeexists and can be recognized by unequalcoloring of both irises
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Thunderclap HeadacheThunderclap Headache
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Headache: DifferentialHeadache: DifferentialDiagnostic OptionsDiagnostic Options
Cervicogenic headache
Tension-type headache
Migraine headache
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Cervicogenic HeadacheCervicogenic Headache
Pain, referred from a source in the neck andperceived in one or more regions of thehead and/or face, fulfilling criteria C and D
Clinical, laboratory and/or imaging evidence ofa disorder or lesion within the cervical spineor soft tissues of the neck known to be, orgenerally accepted as, a valid cause ofheadache
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Cervicogenic HeadacheCervicogenic Headache
Evidence that the pain can be attributed to theneck disorder or lesion based on at leastone of the following:
1. Demonstration of clinical signs thatimplicate a source of pain in the neck
2. Abolition of headache following diagnosticblockade of a cervical structure or its nervesupply using placebo- or other adequatecontrols
Pain resolves within 3 months after successfultreatment of the causative disorder or lesion
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Referral Pattern UpperReferral Pattern UpperTrapezius MuscleTrapezius Muscle
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Referral Pattern LevatorReferral Pattern LevatorScapulae MuscleScapulae Muscle
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Referral PatternReferral PatternSternocleidomastoid MuscleSternocleidomastoid Muscle
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Referral Pattern TemporalisReferral Pattern TemporalisMuscleMuscle
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Referral Patterns Splenius CapitisReferral Patterns Splenius Capitis
(Left) and Cervicis (Right) Muscles(Left) and Cervicis (Right) Muscles
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Referral Patterns SemispinalisReferral Patterns SemispinalisCervicis (Left) and Capitis (Right)Cervicis (Left) and Capitis (Right)
MusclesMuscles
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TensionTension--Type HeadacheType Headache
Hypothesized to be related to myofascialtrigger points
Prolonged nociceptive input may lead tocentral sensitization
Amplification of receptiveness of central pain-signaling neurons to input from low-thresholdmechanoreceptors
Clinically characterized by the presence ofhyperalgesia and/or allodynia
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TensionTension--Type HeadacheType Headache
Headache has at least two of the followingcharacteristics:
1. Bilateral location
2. Pressing/tightening (non-pulsating) quality
3. Mild to moderate intensity
4. Not aggravated by routine physical activity such aswalking or climbing stairs
Both of the following:
1. No more than one of photophobia, phonophobia ormild nausea
2. Neither moderate or severe nausea nor vomiting
Not attributed to another disorder
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Migraine with AuraMigraine with Aura
At least 2 attacks fulfilling criteria 2-4
Aura consisting of at least one of the following, but nomotor weakness:
1. Fully reversible visual symptoms includingpositive features (e.g., flickering lights, spots or lines)and/or negative features (i.e., loss of vision)
2. Fully reversible sensory symptoms includingpositive features (i.e., pins and needles, peri-oralparaesthesiae) and/or negative features (i.e.,numbness)
3. Fully reversible dysphasic speech disturbance
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Migraine with AuraMigraine with Aura
At least two of the following:
1. Homonymous visual symptoms and/or unilateralsensory symptoms
2. At least one aura symptom develops graduallyover ≥5 minutes and/or different aura symptomsoccur in succession over ≥5 minutes
3. Each symptom lasts ≥5 and ≤60 minutes
Headache fulfilling criteria Migraine without aurabegins during the aura or follows aura within 60minutes
Not attributed to another disorder
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CPR Migraine HeadacheCPR Migraine HeadacheDiagnosisDiagnosis
Five questions:
1. Is it a pulsating headache
2. Does it last between 4 and 72 hourswithout medication?
3. Is it unilateral?
4. Is there nausea
5. Is the headache disabling (disruptingdaily activities)?
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CPR Migraine HeadacheCPR Migraine HeadacheDiagnosisDiagnosis
≥ 4 questions yes: LR+ 24 (95% CI: 1.5-388)
3 questions yes: LR+ 3.5 (95% CI: 1.3-9.2)
1 or 2 questions yes: LR+ 0.41 (95% CI: 0.32-0.52)
Mnemonic POUNDing: Pulsating, Duration of4-72 hours, Unilateral, Nausea, Disabling
But note similarity to neurological deficitsnoted in cervical artery dysfunction!
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Relevance thunderclapRelevance thunderclapheadacheheadache
In 27 cases of non-CSMT VAD this headachepreceded the neurological symptoms:
By less than 1 day in < 30% of cases
By 1-3 days in 15%
By 1-2 weeks in 30%
By > 3 weeks in 25%
Terrett AGJ. Vertebrobasilar stroke following spinal manipulation therapy.In: Murphy R. Conservative Management of Cervical Spine Syndromes(2000)
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Risk ManagementRisk Management
Manipulation or mobilization
Type of manipulative technique
Upper versus lower cervical techniques
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Mobilization or Manipulation?Mobilization or Manipulation?
Michaeli (1993): Questionnaire sent tomanipulative physiotherapists in SouthAfrica
228,050 procedures
Only minor adverse effects reported formanipulation
29 patients receiving cervical spinalmanipulation reported 52 complications
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Mobilization or Manipulation?Mobilization or Manipulation?
However:
58 patients receiving spinal mobilization tothe cervical spine reported 129 complications
One mobilization patient suffered a CVA
Implication for risk reduction?
Michaeli A. Reported occurrence and nature of complicationsfollowing manipulative physiotherapy in South Africa. Aust JPhysiother 1993;39:309-315
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Mobilization or Manipulation?Mobilization or Manipulation?
Survey Irish manual physiotherapists
Only three major adverse events allassociated with cervical manipulation
Drop attack, syncope, TIA
Sweeney A, Doody C. Manual therapy for the cervical spine and reportedadverse effects: A survey of Irish manipulative physiotherapists. ManTher 2010;15:32-36.
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Manipulation: Effect ofManipulation: Effect ofTechnique?Technique?
Rotation appears to place the greatest stresson arterial structures, especially in the uppercervical spine
However, Haldeman et al (2002): review 64medicolegal reports
Strokes noted after any type of manipulation
Including rotation, extension, side bending,non-force, and neutral position manipulation
Haldeman S, et al. Stroke, cervical artery dissection, and cervical
spine manipulation therapy. J Neurol 2002;249:1098-1104
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Manipulation: Effect of Level?Manipulation: Effect of Level?
Most reported site of VA damage is atC1-C2
Includes traumatic and spontaneousdissections
Mas JL, et al. Extracranial vertebral artery dissections: A review of 13 cases. Stroke1987;18:1037-1047
Mokri B, et al. Spontaneous dissections of the vertebral arteries. Neurology1988;38:880-885
Saeed AB, et al. Vertebral artery dissection: Warning symptoms, clinical features,and prognosis in 26 patients. Can J Neurol Sci 2000;27:292-296.
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Manipulation: Effect of Level?Manipulation: Effect of Level?
Cervical manipulation definable event withevidence of a mechanical effect
Provided and recorded by third parties unlikeetiologic mechanisms such as shoulderchecking, hair washing, etc.
“Not to say less recordable mechanicalevents are less related to dissection”
Kawchuk GN, et al. The relationship between the spatial distribution of vertebralartery compromise and exposure to cervical manipulation. J Neurol2008;255:371-377.
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Manipulation: Effect of Level?Manipulation: Effect of Level?
Populations studied
5-year retrospective review yielding a cohortof 25 patients with VA dissection not relatedto major trauma or CSMT from FoothillsHospital, Calgary, AB
26 of 64 cases reported by Haldeman et alfrom retrospective case review articleassociated with manipulation
Diagnostic imaging or reports had to beavailable to determine location of VAdissection
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Manipulation: Effect of Level?Manipulation: Effect of Level?
V3 segment most commonly dissected
Prevalence ratio (PR) V3 versus V1prevalence in CSMT group = 8.46(95% CI: 3.53-20.24)
PR V3 versus V1 in non-CSMT group =4.00 (95% CI: 1.43-11.15)
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Manipulation: Effect of Level?Manipulation: Effect of Level?
Note: Higher prevalence irrespective ofexposure to CSMT
“Demonstrates the impact of everydaymovements and postures [on thismechanically more vulnerable segment]”
Age and gender not found to be significantfactors
But: V3 vulnerability augmented by CSMTexposure
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Manipulation: Effect of Level?Manipulation: Effect of Level?
However, multiple site lesions alsosignificantly more common in bothgroups
CSMT: PR = 2.67 (95% CI: 1.98-3.58)
No CSMT: PR = 2.44 (95% CI: 1.81-3.29)
Interpretation?
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Manipulation: Effect of Level?Manipulation: Effect of Level?
Report of compression at C6secondary to osteophyte arisingfrom superior facet C6
Citow JS, Macdonald RL. Posterior decompression of the vertebralartery narrowed by cervical osteophyte: Case report. SurgNeurol 1999;51:495-498.
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Emergency Procedures: WhatEmergency Procedures: Whatif the Unthinkable Happens…?if the Unthinkable Happens…?Onset of symptoms indicated in 138 of 185
cases:
69%: during CSMT
3%: within minutes of CSMT
8.5%: within 1 hour of CSMT
8.5%: 1-6 hours post-CSMT
5%: 7-24 hours post-CSMT
6%: >24 hours post-CSMT
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Emergency Procedures: WhatEmergency Procedures: Whatif the Unthinkable happens…?if the Unthinkable happens…? Do not re-manipulate the patient’s neck
Observe the patient: Transient signsand symptoms or cervicogenicproprioceptive dizziness?
Refer the patient: rescue and recoveryposition, do not give the patientanything to eat or drink (dysphagia),note the time, call 911
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ConclusionConclusion
Manipulation is but one factor in themulti-factorial etiology of CAD
There may be no dangerous techniquesbut rather dangerous patients
Identification of risk factors or signs andsymptoms indicating CAD in progressclearly pose contraindication to manualtherapy
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Any questions?Any questions?