Risk Assessment of the Cervical Spine: A visit to the graveyard & directions for the future

That old chestnut the 'vertebral artery test' has been with us in Physiotherapy for nearly 4 decades, and yet still the arguments rage on about its clinical use. 

Confusion is never helpful in a clinical (or any) situation, so I've tried to make sense of the background, the logic and ongoing discussion regarding the use of 'the test that refused to die'.

Inspired by the recent debates within the literature, I've put together 3 SHORT FILMS.

Film I, discusses the history of the development and early use of the test. Film II uses some case studies to test the test, and then Film III, takes to the graveyard of old worn out tests, and attempts to offer some logical directions for the future for ALL clinicians working with neck pain, headache, dizziness and visual disturbances.

The key message, is that risk assessment of the cervical spine is relevant for ALL clinicians and NOT (as previously suggested) just for those who practice manual therapy. 

What we know from medico-legal cases is that delays to diagnosis and appropriate management can occur for a range of reasons. It may focus the mind to know that some medico-legal cases I've worked on, have involved assessment of the cervical spine (without intervention).

Hopefully, these films and the case studies contained within them will help to guide clinicians with their problem solving and clinical reasoning, in the quest for safe and efficient practice.

I. The Vertebral Artery Test - A SHORT FILM (Part I)

A short educational film about the long and tortuous history of the 'vertebral artery test', of interest to any clinician who manages patients with cervical spine issues.

II. The Vertebral Artery Test Part II: Risk assessment of the cervical spine

Part II of III, taking a look at the vertebral artery test from the perspective of NON manual therapists. Putting things into context using 4 case scenarios, with regard to risk assessment of the cervical spine. The video covers the umbrella concept of 'cervical arterial dysfunction'.

III. Cervical Spine Risk Assessment: Directions For The Future 

    A SHORT FILM (Part III)

Part III of the vertebral artery videos, takes us to the graveyard of tired old clinical tests, and moves on to offer some directions for the future for risk assessment of the cervical spine. A consideration of blood pressure, cranial nerve examination and sensorimotor testing is incorporated into the clinical case studies that provide background for the video/vlog.

Find more detail at: https://www.trustme-ed.com/lectures/cervical-arterial-dysfunction-moving-forward-with-alan-taylor/alan-taylor-part-3 Look out for the 'Cervical Spine: Risk & Rehabilitation online resources from Alan Taylor & Roger Kerry ... coming soon.

Author: Alan J Taylor is a writer and critic who tries to think about stuff . He works as a Physiotherapist, University Assistant Professor and Medico-Legal expert witness whilst maintaining a small clinical work load. The views contained in this blog are his own and are not linked to any organisation or institution.  He once rode the Tour of Britain and worked as a cycling soigneur. He still enjoys riding a bicylce through the leafy lanes of Nottinghamshire and Derbyshire. In a World full of conflict and division ... like Bukowski, he 'writes to stay sane'.

Death following a neck injury: What can we learn from the case of Katie May?

This commentary was originally written as a general interest article for publication on a Web news page. For one reason or another it was not published ... So here it is, in a modified Blog format.

Katie May, a 34 year old Playboy model and entrepreneur, died on February 4th 2016 following a stroke. Whilst the details are sketchy, media reports of a neck injury during a photo shoot raises questions as to how a fit healthy 34 year old, could go from an apparent neck strain to a fatal stroke in a matter of days. This report takes look at the mechanisms of early stroke and considers what we can learn from the case.

Neck pain is a common complaint that is thought to affect around 10-13% of the population. However, most patients do not have a life threatening condition. That said the cervical blood vessels can be susceptible to injury. This was illustrated graphically by the tragic death of Australian Cricketer Phillip Hughes. Hughes died from a sub arachnoid haemorrhage (bleed to the brain) following a blunt injury to a blood vessel in his neck from a cricket ball.

The blood flow to the brain is carried by two small vessels at the back of the neck called vertebral arteries, and two larger vessels at the front, called the carotid arteries. The carotids carry around of 80% of the blood flow to the brain. It is well known that any of these blood vessels can be injured by trauma or affected by disease. It is well known that the early presenting symptoms of arterial dissection may be neck pain or headache and that ischaemic symptoms may not develop until later.

A complex anatomical region ... https://www.flickr.com/photos/thomasfisherlibrary/12288500023

So, how could an apparently fit, healthy female, suffer a stroke leading to death at the age of 34?

The complete picture of exactly what happened in this case remains unknown, but we can learn from past experience. There are a number of potential scenarios.

One scenario is that like Phillip Hughes, Katie May had perfectly HEALTHY blood vessels that were injured internally (arterial dissection) by an ‘awkward’ fall during a photo shoot. What happened thereafter remains open to speculation. At that point ANY intervention whether it was advice (to keep moving), pain management/education or manual therapy/manipulation, may have ended with the same outcome.

It remains unexplained how some dissection pathologies resolve yet others go on to lead to stroke or death. It is thought that this may relate to variety of intrinsic conditions linked to connective tissue disorders and clotting factors. In addition, extrinsic factors may also play their part. A failure to recognise the signs and symptoms (assuming there were any) of a developing pathology in accident and emergency, at the GP practice, or under the care of a musculoskeletal therapist (Physiotherapist, Osteopath, Chiropractor) may be also be associated with fatal consequences. A common medico-legal scenario, is a delay to appropriate triage, in order to commence a trial of management or specific treatment.

 
 Thrombotic stroke - image en.wikipedia.org550 × 800Search by image 

A second scenario of many, is where a person develops musculoskeletal neck pain insidiously or via a minor trauma and seeks the attention of a manipulative therapist, such as a Chiropractor, Osteopath or Physiotherapist. Katie May Tweeted that she was going to see her Chiropractor, though no detail has been released. However, the wave of assumption and speculation implicating Chiropractors, could well be entirely unfounded as this single case study clearly illustrates. 

The status of the blood vessels at the time of ANY consultation, may be either healthy OR unhealthy. Unfortunately, without sophisticated equipment, there is no way of knowing whether vessels may be ‘weak’ or suffering from underlying disease such as fibromuscular dysplasia or atherosclerosis (rare in the younger patient). This is one of the reasons that manipulation in particular, has been called into question. At best the science remains equivocal. A recent systematic review found no association and suggested that, "the relative risk of ICA dissection after cervical spine manipulation compared with other health care interventions for neck pain, back pain, or headache is unknown". However, critics argue that spinal manipulation to the neck may injure vessels, leading to stroke.

Neck manipulation has many descriptions, but generally involves a high velocity manoeuvre, outside the control of the patient, which may produce a click or crack. There is evidence to suggest that for acute/subacute neck pain, cervical manipulation provides better pain relief and functional improvement than medications such as varied combinations of NSAIDs, analgesics and muscle relaxants. However, the caveat is that this benefit, may not be entirely risk free. Furthermore, it is suggested that the actual number of adverse events (injury, stroke, death) may be massively under reported. 

 

thebluediamondgallery.com1200 × 755Search by image

Could the risk be reduced?

The debate on the safety of manipulation has not been helped by the lack of agreement on the risk of blood vessel injury following treatment. Some reports suggest ratios between one in 50 ,000 to one in nearly 6 million manipulations, though as mentioned, many question the accuracy of this data, citing up to 100% under-reporting. A review of 134 case reports, published in 2012, said, “there was potential for a clinician to prevent 44.8% of adverse events (such as stroke or death) associated with manipulation”. The authors suggested, “10.4% of the events were unpreventable”. Interestingly, the patients who died had continued or excessive spinal manipulation, despite the fact that they were not responding to treatment, or their symptoms were worsening.

Despite RCT reports that in apparently healthy vessels, manipulation to the atlanto-

axial joint does NOT appear to increase mechanical stress on the vertebral artery, it remains unknown what the affect might be on diseased, weak or already dissecting vessels (vertebral or carotid).

As it stands, scientific knowledge can neither accurately quantify the risk associated with neck manipulation, nor establish an unequivocal link between manipulation and adverse events. A 2016 physiotherapy publication, a profession that has been prominent in the field of neck risk assessment, suggested that, at best, “early recognition of injury to blood vessels” may reduce the occurrences of inappropriate treatment. This raises the important question of what exactly is 'inappropriate treatment'? Whilst manipulation may have been demonised by some, it is important to understand that blindly defaulting to ANY favoured intervention in the absence of sound clinical examination and risk assessment ... may lead to adverse outcomes in the presence of arterial injury.

Could tragic events like this be prevented?

Disappointingly, the complexity of the human body and mind, dictates that the answer will vary from case to case and clinician to clinician. It remains essential for ALL CLINICIANS to retain an index of suspicion for arterial injury in cases of trauma, be cognisant of ‘red flags’ and apply appropriate clinical reasoning and examination procedures. A default to, a single school of thought or approach (whatever that may be), may lead to delays to triage, inappropriate management and potential medico-legal consequences. 

Atypical, worsening presentations, with OR without subtle ischaemic symptoms may alert the clinician to the presence of arterial injury. The diagnosis of arterial dissection rests on a careful clinical history, physical examination, and targeted ancillary investigations. Clinicials should be cognisant that delay may be fatal.

What do we all have to learn from cases like this?

1. Retain an index of suspicion for vascular injury in trauma cases. 

2. Know your anatomy and pathophysiology.

3. Hurt does = harm, in some cases. 

4. Examine and question the patient in detail.

5. Have, and retain vigilance for ‘Red Flags'.

6. A DELAY to appropriate management, is a common root cause in many medico-legal cases.

 ... There is NEVER absolute certainty

 

HT to Woody  Guthrie for being an inspiration -  "It's a folk singers critical thinkers job to comfort disturbed people and to disturb comfortable people"

Author: Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist, University Assistant Professor and Medico-Legal expert witness ... The views contained in this blog are his own and are not linked to any organisation or institution. Like Bukowski, he 'writes to stay sane'.

You'll find him mostly on Twitter https://twitter.com/TaylorAlanJ

5 good reasons for manual therapists to take blood pressure

1.    Risk assessment – The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) produced a seminal consensus document for cervical spine risk assessment (Rushton et al, 2012). The accompanying paper available here http://www.sciencedirect.com/science/article/pii/S1356689X13001926
details a core shift in thinking about vascular risk and manual therapy. One of its key recommendations is that manual therapists consider incorporating blood pressure testing into their toolkit for risk assessment prior to treatment.

The concept of haemodynamic awareness is not limited to the cervical spine. It is known that simple therapeutic exercise can have haemodynamic implications throughout the body. There are systemic vascular responses to a range of therapeutic interventions such as lumbar mobility exercises in healthy subjects (Al-Obaidi et al, 2001). It is currently unknown what the responses might be in individuals with underlying pathology such as abdominal aortic aneurysm or atherosclerotic plaque. Clinicians have a duty to make appropriate risk assessment prior assessment, manual therapies or exercise prescription. The assessment of blood pressure may be a component of this process for some patients.

2.    Health Check? - In the UK, high blood pressure is one of the most important preventable causes of premature ill health and death. It is identified as a major risk factor for stroke, heart attack, heart failure, chronic kidney disease and cognitive decline. It has also been identified as a focus of the NHS ‘Health Check’ drive, (http://www.healthcheck.nhs.uk/).

Patients visit physiotherapy departments for a variety of musculoskeletal (MSK) complaints which may be associated with other health issues or co-morbidities. Physiotherapists should be cognisant with a patient’s blood pressure status from a health assessment perspective (Taylor and Kerry 2013). It is known that some conditions of vascular origin may mimic MSK conditions i.e. abdominal aortic aneurysm, impending stroke (Kurihara 2007).

In the United States this concept is well recognised and the American Physical Therapy Association produced a Guide to Physical Therapist Practice (2001) which made the recommendation that patient examination should begin with a history and systems review which includes “anatomical and physiological status of the cardiovascular/pulmonary system, integumentary, musculoskeletal and neuromuscular systems”. The guidance went on to say, “Heart rate and BP are measured to assess aerobic function and circulation, these measures can assist the physical therapist in identifying cardiovascular or pulmonary problems that might affect prognosis and intervention or require referral to another practitioner.”

It is an unfortunate reality however, that many clinicians do not see the relevance to their practice, which poses the question of whether they are cognisant of their unique role and opportunity, to play a part in the health and wellbeing of their patient population. http://www.csp.org.uk/frontline/article/second-opinion-exercise-life

3.    Clinical Reasoning – Vascular tissue contains nociceptors and may be source of local PAIN… Manual therapists treat PAIN and should be cognisant of that within their clinical reasoning.
It is well recognised that vascular tissue and mechanisms of cervical arterial dysfunction (CAD) may give rise to pain in the cranio-cervical region (Taylor and Kerry 2005). It is perhaps less well known that vascular tissue can be the source of pain syndromes throughout the body, ranging from the obvious – abdominal aortic aneurysm (low back pain), through to the less obvious (or less well known) distal limb pain/numbness as a result of popliteal artery entrapment syndrome (PAES). PAIN may be local due to a nociceptor response in the tunica adventitia due to underlying pathology (arterial dissection, atherosclerosis, aneurysm) or distal due to ischaemia (which may be movement or exercise induced).

4.    Medico-Legal – Enough has been written in the manual therapy literature for a healthy evidence base to underpin both practice and clinical reasoning. The job of an expert witness is to assess whether a practitioner is acting according with contemporary evidence and in the way that a reasonable body of similar professionals would. Certainly in the cervical spine, the 2012 IFOMPT cervical spine risk assessment document provides clinicians with the current best evidence level and guides assessment, decision making and practice.
http://nvmt.fysionet.nl/ifompt/ifompt-examination-cervical-spine-doc-september-2012-definitive.pdf


Elsewhere, from an anatomical perspective, there is an increasing body of literature relating to ‘altered haemodynamics’ throughout the body. What may surprise clinicians is that this work relates to a wide range of groups or profiles, from elite athletes (Bender et al, 2012) through to elderly diabetics with atherosclerosis (Chin 2014). As manual therapists are in the business of manipulating, mobilising, moving and prescribing movement based exercises there is a need to be aware of haemodynamic theory and the relevance to active and passive interventions.

Working as an expert witness in the field of clinical negligence and altered haemodynamics has raised my own awareness of the need for therapists in a range of specialties, to give consideration to BP. Furthermore, it seems and that adverse events are NOT confined to manipulation and may occur after examination or exercise prescription. This is a sobering thought and one which clinicians would be wise to cognisant of.

 

5.    Cos you know it makes sense! - I haven’t got time for all these extra tests is the common cry. Well IFOMPT have cleverly suggested that you should find time! Perhaps consider re-ordering your routine physical testing. In other words, if you have an index of suspicion of CAD following the patient interview, then it may be prudent (for all of the above reasons) to consider a cursory BP check. It actually takes about two minutes of your time. BUT may save you hours!

Oh, and BP measurement is increasingly being performed by fitness instructors and Sports Rehabilitators... Don't get left behind!

... and if the results surprise you... What then ???
http://www.nice.org.uk/nicemedia/live/13561/56015/56015.pdf will help to guide your clinical reasoning. The answers are often not clear cut and should be considered on a case by case basis, when ALL of the relevant imformation has been gathered. For case by case examples see ... http://www.ncbi.nlm.nih.gov/pubmed/23021565

KEY ADVICE - Read the salient points in the IFOMPT document ...

DON'T RELY on one single test to make your decision  (i.e. just the blood pressure values ... Unless they are dangerously high - >180/110 see NICE Clinical Guideline 127 ...

For values below that threshold ... consider the whole patient presentation and the range of potential pathologies, as described in the IFOMPT document. Specific case studies can be found at http://www.physiospot.com/research/vascular-profiling-should-manual-therapists-take-blood-pressure/

For more information on blood pressure measurements go to: http://www.cpptjournal.org/pdfs/members/fulltext/2011/june/blood_pressure.pdf

 

Author

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

He has worked as a lecturer in Physiotherapy and Sports Rehabilitation & Exercise Science at the University of Nottingham since 2010.

He worked full-time as a clinician until joining the UoN and maintains a clinical case load via his Consultancy, which regularly takes him to to some of the UK's leading sports clubs. He deals with a variety of pain and performance related cases, many with a haemodynamic bias. 

https://twitter.com/TaylorAlanJ

References
   
Al-Obaidi S, Anthony J, Dean E, Al-Shuwai N (2001) Cardiovascular responses to repetitive McKenzie lumbar spine exercises Phys Ther. 81(9):1524-33.

Bender MH, Schep G, Bouts SW, Backx FJ, Moll FL (2012) Endurance athletes with intermittent claudication caused by iliac artery stenosis treated by endarterectomy with vein patch--short- and mid-term results. Eur J Vasc Endovasc Surg. 43(4):472-7. doi: 10.1016/j.ejvs.2012.01.004. Epub 2012 Jan 20.

Chin JA, Sumpio BE (2014) Diabetes mellitus and peripheral vascular disease:
diagnosis and management. Clin Podiatr Med Surg. 31(1):11-26. doi: 10.1016/j.cpm.2013.09.001. Epub 2013 Nov 7. PubMed PMID: 24296015.

Guide to physical therapy practice. 2nd ed. Alexandria, Va: American Physical Therapy Association; 2001. P. 28.

Kurihara, T. (2007). Headache, neck pain, and stroke as characteristic manifestations of the cerebral artery dissection. Intern Med 46(6): 257-258.


Taylor AJ, Kerry R (2013) Vascular profiling: should manual therapists take blood pressure? Man Ther. 18(4):351-3. doi: 10.1016/j.math.2012.08.001. Epub 2012 Sep 25.


Taylor AJ, Kerry R (2005) Neck pain and headache as a result of internal carotid artery dissection: implications for manual therapists. Man Ther. 10(1):73-7.


http://nvmt.fysionet.nl/ifompt/ifompt-examination-cervical-spine-doc-september-2012-definitive.pdf

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...!)

http://www.medical-artist.com/cranial-nerves.html
Medical illustrations of the cranial nerves by Joanna Culley of Medical-Artist.com

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.

http://tinyurl.com/bpkj2xw

 

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

References

International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention (2012) http://www.ifompt.com/site/ifompt/files/pdf/Standards%20Committee/Standards%20Committee%20Documents//IFOMPT%20Examination%20cervical%20spine%20doc%20September%202012%20definitive.pdf

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

Education 

Anatomy Video (Armando Hasudungan)


Cranial Nerves - functions and disorders 
 
Cranial nerves - http://prezi.com/l-chg-rsdkf5/cranial-nerves/

Physiotherapy UK Congress 2013 -  http://prezi.com/yv9w6ixyjbrn/cervical-spine-risk-assessment-rehabilitation-guidance-for-safe-effective-clinical-practice/

One minute medical school - Cranial Nerves  

Cranial Nerve OSCE examination 

Two minute CN Examination

Author

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. 

https://twitter.com/TaylorAlanJ