cervical artery dysfunction: implications for physiotherapy diagnosis and management

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

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

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

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

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

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…


Rotary neck manipulation resulted ininability to turn head

That night she kept walking into thingsat work

Another visit to chiropractor next day


Neck adjustment

Patient immediately began to cry

Left eye rolled up, right roamedrandomly

Convulsions


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


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


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.


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

Relevance to PhysiotherapyRelevance to Physiotherapy

Now wait a minute…



Why would we as physiotherapists beworried about the association betweenmanipulation and stroke?



Why would we as physiotherapists beworried about the association betweenmanipulation and stroke?

Isn’t this purely a chiropractic problem?

Clinical VignetteClinical Vignette

63-year old male

Hypertensive

Right cerebral infarct five years earlier

Four months previously vertebrobasilarinfarct


PHYSIOTHERAPIST applied cervicalmanipulation

Immediate dizziness post-manipulation

Over the next few hours dysarthria,dysphagia, and left-sided paralysis

Medullary infarct

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.

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.


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.



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.


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.


Note the extremely low incidence ofCAD and even lower incidence of CAD-associated CVA in the generalpopulation

Remember this when establishingpretest probability

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

Anatomy: ArteryAnatomy: Artery

Three-layer structureartery

Intima

Media

Adventitia


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


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


ADVENTITIA

Longitudinally oriented Type I collagenand elastic fibers

Gradually becomes continuous withenveloping connective tissue

Junqueira LC, et al. Basic Histology. 8th ed (1995)

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

Subintimal HematomaSubintimal Hematoma

Disruption vasavasorum leads tosubintimal bleedingand occlusion of VAlumen

May also causevasospasm

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

Intimal Tear with EmbolizationIntimal Tear with Embolization

Propagating clotextends into lumenand breaks off

Embolus

Distal arterialocclusion andinfarction

Dissection and SubintimalDissection and SubintimalHematomaHematoma

Disruption intima andinternal elastic lamina

Blood dissects theselayers from muscularmedia: dissectinganeurysm

Compresses lumen

Exposure sub-endothelial tissue andthrombosis

Dissection and SubintimalDissection and SubintimalHematoma: ReperfusionHematoma: Reperfusion

Hemorrhage mayagain rupturethrough intima

Reestablishescommunication withtrue lumen

Recanalization mayoccur

Dissection with PseudoDissection with Pseudo--AneurysmAneurysm

Disruption of media,internal elastic lamina,and intima

Pseudo-aneurysmunder extendingadventitia

May propagate distally

Frequent cause ofocclusion PICA

False AneurysmFalse Aneurysm

Disruption total arterialwall

Peri-arterialhemorrhage containedin fascia

External compressionlumen

Turbulence in lumenmay cause thrombusand embolus formation

Anatomy: Vertebral ArteryAnatomy: Vertebral Artery

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

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

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?

AtlantoAtlanto--Axial Segment andAxial Segment andRotationRotation

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

V4: Subforaminal and IntraV4: Subforaminal and Intra--CranialCranial SegmentSegment

Pierces the posterior atlanto-occipitalmembrane and dura and arachnoidmater

Courses on intra-cranially insubarachnoid space

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

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

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?

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

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.

Anatomy: Internal carotidAnatomy: Internal carotidarteryarteryFig 2

C6

C1 (atlas)

Vertebral ArteryInternal Carotid Artery

Anatomy: ICAAnatomy: ICA

Provides 80% of blood flow to the brainversus 20% supplied by thevertebrobasilar system

Traverses sternocleidomastoid, longuscapitis, stylohyoid, omohyoid, anddigastric muscles

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

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

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?

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

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

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

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

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.


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


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


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)

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.

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.

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.


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.


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.


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


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.


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


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


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


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


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


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


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


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


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


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


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

Clinical decisionClinical decision--makingmaking

Evidence for effectiveness

Evidence for risk of harm

Risk-benefit analysis

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


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.


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

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.


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.


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.


RCT comparing chiropractic cervicalmanipulation to mobilization

85 of 280 patients reported advesreevent

Manipulation group: 48 patients with120 complaints

Mobilization group: 37 patients with 92complaints


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.


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.

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)

Serious ManipulationSerious Manipulation--RelatedRelatedAdverse EventsAdverse Events

Two types of vertebral arterystroke:

1. Wallenberg syndrome

2. Locked-in syndrome

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


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)


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

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”


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


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

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)

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

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


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


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.


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)


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


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


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.

BradfordBradford--Hill Criteria #2Hill Criteria #2 -- #3#3

Proposed cause temporally related tooccurrence

Consistent across different samples andgroups

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


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)


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


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


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


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


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

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)

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

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


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


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


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)


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)


“… [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.

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

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

Direct Vessel Trauma:Direct Vessel Trauma:

Manipulation

Whiplash

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

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

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

Not all Dizziness Implies CADNot all Dizziness Implies CAD

Benign Paroxysmal Positional Vertigo

Cervicogenic dizziness

Vertebrobasilar insufficiency

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

HallpikeHallpike--Dix ManeuverDix Maneuver

Positionalnystagmus on thistest has been shownto identify patientswith posterior SCCBPPV with 78%sensitivity

Specificity as highas 88% has beenreported

Age: 30Age: 30--45 year old?45 year old?

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

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.

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%?

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

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.

ArteriopathiesArteriopathies

Marfan syndrome

Ehlers-Danlos syndrome

Fibromuscular dysplasia

Cystic medial necrosis

Osteogenesis imperfecta

Alpha-1-antitrypsin deficiency

Autosomal dominant polycystic kidneydisease

Previous CAD

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

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

Hypermobility: Beighton ScoreHypermobility: Beighton Score

Hypermobility: Brighton CriteriaHypermobility: Brighton Criteria

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

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

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

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

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

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


• 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


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

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

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.

Cardiovascular Risk FactorsCardiovascular Risk Factors

Hypertension

Tobacco use

Hypercholesterolaemia

Diabetes

Atherosclerosis

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

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)

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%

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

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


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


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

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


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

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

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

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

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

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)

Systematic Review of RiskSystematic Review of RiskFactors CADFactors CAD

Systematic review risk factors cervicalartery dissection

Two computerized databases, 1966-2005

31 case control studies


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…


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

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…

Clinical DiagnosisClinical Diagnosis

Two relevant questions…

First Relevant QuestionFirst Relevant Question

How do we identify patients at riskfor cervical artery dysfunction?

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…

Second Relevant QuestionSecond Relevant Question

How do we identify patients with cervicalartery dysfunction in progress?

They are not all this easy…They are not all this easy…

Presenting Complaint?Presenting Complaint?

Major presenting complaint of 137patients who subsequently had an SMT-induced vertebrobasilar vascularincident

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)

So Where Does This LeaveSo Where Does This LeaveUs?Us?

Presenting complaint provides norelevant information

Physical Examination?Physical Examination?

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

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

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

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

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.

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


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.


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.

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


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


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?


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


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

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?


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


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

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

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)

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?

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

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

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

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

NystagmusNystagmus

Positional downbeat vertical or skewnystagmus: Posterior fossa lesions(Arnold-Chiari malformation or anothercompressive lesion at the foramenmagnum)

NystagmusNystagmus

Pendular nystagmus occurs mostcommonly in patients with multiplesclerosis and brain stem stroke

Cervical Artery DysfunctionCervical Artery Dysfunction

Non-ischaemic signs and symptoms

Ischaemic signs and symptoms

Vertebrobasilar system

Internal carotid artery

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

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

Ischaemic Signs andIschaemic Signs andSymptoms VASymptoms VA

Malaise

Perioral dysaesthesia

Photophobia

Clumsiness

Agitation

Cranial nerve palsies

Hindbrain stroke: Wallenberg or locked-insyndrome

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

NonNon--Ischaemic Signs andIschaemic Signs andSymptoms ICASymptoms ICA

Ipsilateral carotid bruit

Neck swelling

Scalp tenderness

Anhydrosis face

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

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

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


Large study of hospitalized patientswith CAD

Only 7% had cranial 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) + -

Horner SyndromeHorner Syndrome

Four physical signs: miosis, ptosis,enophthalmos, and anhydrosis

Miosis or inability to dilate a pupil

Paralysis of the dilatator pupillae muscle


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


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


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


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


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

Thunderclap HeadacheThunderclap Headache

Headache: DifferentialHeadache: DifferentialDiagnostic OptionsDiagnostic Options

Cervicogenic headache

Tension-type headache

Migraine headache

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

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

Referral Pattern UpperReferral Pattern UpperTrapezius MuscleTrapezius Muscle

Referral Pattern LevatorReferral Pattern LevatorScapulae MuscleScapulae Muscle

Referral PatternReferral PatternSternocleidomastoid MuscleSternocleidomastoid Muscle

Referral Pattern TemporalisReferral Pattern TemporalisMuscleMuscle

Referral Patterns Splenius CapitisReferral Patterns Splenius Capitis

(Left) and Cervicis (Right) Muscles(Left) and Cervicis (Right) Muscles

Referral Patterns SemispinalisReferral Patterns SemispinalisCervicis (Left) and Capitis (Right)Cervicis (Left) and Capitis (Right)

MusclesMuscles

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

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

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

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

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)?

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!

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)

Risk ManagementRisk Management

Manipulation or mobilization

Type of manipulative technique

Upper versus lower cervical techniques

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


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


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.

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

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.


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.


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


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)


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


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?


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.

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

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

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

Any questions?Any questions?

cervical artery dysfunction: implications for physiotherapy diagnosis and management

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