Wednesday 9 October 2013

Cranial nerve testing & cervical spine risk assessment – A ‘no brainer’!

Straw poll anyone...?

Hands up manual therapists ... if you would perform a neurological examination (upper limb/lower limb/UMN), if a patient’s subjective history indicated that you should………..
GOOD, that’s pretty much 100% of you then?

Hands up ... if you would perform a cranial nerve examination if a patient’s subjective history indicated that you should…. Mmmm, I suspect that result is well below 100% (amongst physiotherapists for sure...!)
Medical illustrations of the cranial nerves by Joanna Culley of

For decades, manual therapists worldwide, have talked about the importance of the D’s (dizziness, drop attacks, diplopia, dysarthria and dysphagia) and N’s (numbness, nausea and nystagmus) when taking a subjective history in patients’ suspected of having ‘vertebrobasilar insufficiency’ (VBI). 

In the same way physiotherapists in the UK, were traditionally taught to perform a thorough neurological examination in upper and lower limbs, in cases of suspected neurology or upper motor neurone dysfunction.

So why did we never really get to grips with cranial nerve examination in suspected cervico-cranial neurology? There’s no point in looking back really (though a few educationalists might shift awkwardly in their seats), the plain stark fact is that we have been missing a trick! The D’s and N’s we diligently worried so much about, were simply subjective manifestations of cranial nerve dysfunctions linked to brain ischaemia.

Frankly, it is that simple. A well-performed CN examination may provide key information to assist in the clinical reasoning, risk assessment and triage process. That is why it appears as a prominent part of the 2012 IFOMPT International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention ... A somewhat long winded name, for what is essentially a cervical spine risk assessment document.

The IFOMPT document was achieved via protracted International consensus and represents the best level of evidence we currently have. Therapists would be wise to avail themselves of the key recommendations for practice contained in the document. Some key points are mentioned below, BUT … the author advises reference to the complete document for balance.

Implications for practice

There are serious conditions, which may mimic musculoskeletal (MSK) dysfunction in the early stages of their pathological progression.
1.     Cervical arterial dysfunction
2.     Upper cervical instability

This basically means that manual therapists need to possess the tools by which they can make informed decisions about risk, from a subjective and objective perspective.

A comprehensive list of risk factors and differential diagnosis table is contained within the IFOMPT document (pp 13-14). There are also some useful case histories which help to put this into perspective (pp 15-16)

Clinical decision-making

Some important points are made with regard to decision making for the physical examination are also highlighted.

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

·Are there any precautions to orthopaedic manual therapy OMT?
·Are there any contraindications to OMT?
·What physical tests need to be included in the physical examination?” (IFOMPT 2012)

The above are generally normal practice for most experienced manual therapists. However, the following two items, frankly should be normal practice also, but are explicit in the document.

What is the priority for these physical tests for this specific patient? What is the order of testing and to which tests should be completed at the first visit?

·Do the physical tests need to be adapted for this specific patient?" (adapted from IFOMPT 2012)

Implications for clinicians

Well simply, there is an International guidance document, which suggests you need to think carefully about HOW TO PROCEED with your physical examination. The clinician may be wise not to launch into a ‘routine examination’ and this has obvious medico-legal implications.

What does that mean practically?

Essentially, that clinicians should, from a detailed subjective history and sound clinical reasoning, be able to adapt their clinical examination (and order of) accordingly. This may, based on the findings of the subjective history include a consideration of upper cervical instability, high or unstable blood pressure and cervical arterial dysfunction. 

A series of possible actions are described in full, in the IFOMPT document (pp 18-21)

I will draw your attention to the specific sections on cranial nerve examination and blood pressure testing (which I cover in a separate blog), which may form part of the physical examination.

Clinical pearls


1.     Cranial nerve testing is an essential part of physical examination in the presence of neurovascular signs and symptoms in the cranio-cervical region

2.     Physical examination involves movement and that alone may cause neurovascular compromise

3.     Remember, this is no longer just about the vertebral artery – USE SYSTEM BASED THINKING

4.     Cases of arterial compromise have been documented (usually as medico-legal cases) linked to EXAMINATION only! 

5.     Remember, this is no longer just about just arterial dissection

6.     Clinicians should be aware of the range of arterial pathologies and their potential links to movement based therapies NOT JUST MANIPULATION!

7.     GOOD NEWS …Physiotherapists are currently World leaders in guiding practitioners toward safe, evidence based practice and risk assessment in the cervical spine

It is in your interest as a clinician (at every level) to be familiar with IFOMPT 2012


International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention (2012)
Taylor AJ, Kerry R (2010) A systems based approach to risk assessement of the cervical spine prior to manual therapy. International Journal of Osteopathic Medicine 13(3):85-93

Kerry R, Taylor AJ (2009) Cervical arterial dysfunction: knowledge and reasoning for manual physical therapists. Journal of Orthopaedic and Sports Physical Therapy 39(5):378-387


Anatomy Video (Armando Hasudungan)

Cranial Nerves - functions and disorders 
Cranial nerves -

Physiotherapy UK Congress 2013 -

One minute medical school - Cranial Nerves  

Cranial Nerve OSCE examination 

Two minute CN Examination


Alan J Taylor  - is a medico-legal expert witness, in the field of clinical negligence related to manual therapy and stroke.

He works as an Assistant Professor in Physiotherapy and Sports Rehabilitation & Exercise Science at the University of Nottingham.

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