red flags CAD

Question 1

vertebral artery

Answer 1

rotation mainly takes place at C1-2
vertebral artery passing through cervical spine to circle of willis have to deal with excessive amount of rotation
vertebral artery sharp turn to left
withstand 45 degrees of rotation

carotid and vertebral artery
internal carotid much larger - more contribution
circle of willis allows 4 arteries to contribute to blood flow to brain

Question 2

VBI = carotid artery dysfunction

Answer 2

Ext / Rotn can compromise Vertebral Artery. if you extend neck reduce flow rates in arteries or if you rotate. shouldnt be a problem for arteries if they’re normal.
Atherosclerotic changes inside VA can further limit blood flow
Cervical osteophytes can compromise Vertebral Artery
Upper cervical instability can cause VBI – RA, Down’s syndrome, post RTA (6/52)
CAD – Cervical Artery Dysfunction is better term to encompass ICA and VA insufficiency – shift in language

craniovertebral instabiltiy - changes to vertebral arteries
post RTA - increased movement in cervical spine
subtle ligamentous injuries - alar ligaments
temporary increase in movement

5 Ds – Dizziness, Diplopia, Dysphagia, Dysarthria, Drop Attacks
3 Ns – Nausea, Numbness, Nystagmus

could have occluded cervical artery and be asymptomatic

Question 3

APA clinical practice guide

Answer 3

dizziness
diplopia - double vision / loss within visual field
dysarthria - difficulty with speech
dysphagia - difficulty swallowing / unexplained hoarse voice
drop attacks - sudden collapse without LOC

Nystagmus (spontaneous)
nausea / vomitting
numbness / paraesthesia

Question 4

CAD incidence

vertebral artery dissection

Answer 4

Annual incidence CAD = 2.6 persons per 100,000 population (95%CI 0.9 to 4.2)
Carotid or VA dissection is a common cause of stroke in under 45s – can be induced by sudden neck movement, coughing or visiting hairdresser / dentist. Incidence ICAD vs. VAD = 2:1

Vertebral Artery Dissection
20-45 years – females > males
Acute neck pain / headache (spontaneous – no trauma)
Headaches (‘unlike any other’) / neck pain may be an early presentation of unravelling vascular pathology in VA or Internal Carotid artery e.g.
arterial dissection leading to stroke,
VA spasm post-RTA etc.
CV risk factors should increase suspicion of CAD: HTN, Hi Chol, Type 2 DM, Smoking, BMI > 25 kg/m2
Clinically watch out for hypertension, cranial nerve exam findings!

• induced by very sudden neck movements
• or dentist or hairdressers- extended extension
• evolve over few days
• most common to spontaneously resolve
• clinical watch hypertension
• watch nerves
• BP cuff important to have

Question 5

angiogram

Answer 5

fall with hyperextension of the head

shows blockage

Question 6

CAD clinical concerns

Answer 6

People presenting for physio with evolving vascular pathology
Effective Diagnostic Triage
Can we safely identify those patients presenting with CAD?
Do no harm

Neck Movement (Ax or Rx) can compromise blood flow and result in an adverse event in response to –
Gr V Manipulation
EOR MT e.g. Mulligan’s MWM / SNAGS
AROM HEP – rotation / extension

• any position that has potential to compromise blood flow

Question 7

CAD subjective findings

Answer 7

Subjective Findings:
Pt under 55yr
Acute onset unilateral unfamiliar neck pain & HA
Mod-severe pain; ofter progressing
Current / past Hx Migraine - higher incident of cervical artery dysfunction
Hx of CxSp trauma
Spontaneous onset of pain related to sudden neck movement -
Recent RTI (within last 7/7)
Recent unfamiliar neuro symptoms – 5Ds & 3Ns
Balance, Speech, vision
Horner’s syndrome
Hx HTN & other CV risk factors (more VBI)

ptosis and miosis - horners syndrome
may show up with CAD

Question 8

CAD physical exam

Answer 8

Physical Exam -Validity / reliability & safety of tests??
Watch out for developing neuro symptoms & signs during or after OR Anything of concern
Check Balance, Gait
Cranial Nerve exam
VBI - Rotn hold 10secs – monitor 10secs - report 5 Ds or 3 Ns - look for ongoing symptoms that does not settle
Watch for dizziness / nystagmus which does not settle in few secs
Cease testing if symptoms not settling or getting worse
ED referral with letter
APA CPG 2017
Imaging - Doppler Ultrasound / MR angiography to confirm

slowness to settle - main help with differentiating between vestibular and CAD

Question 9

best practice CxSp exam

Answer 9

APA (2017): Clinical Guide to Safe Manual therapy Practice in the Cervical Spine

IFOMPT Guidelines 2012:
Clinical Reasoning – Subjective Hx++
Sustained end-range rotation - the most provocative and reliable test (Mitchell et al, 2004).
Sustained pre-manipulative test position (Rivett et al, 2006).

Australian (APA) Manip Physio Testing Protocol (2006) Manipulation and EOR physiological techniques contraindicated with VBI

Question 10

clinical practice points

Answer 10

Movement reduces blood flow through neck
EOR positions reduce blood flow through neck
Rotation
Extension
Suspicion of acute sudden neck / head pain ‘unlike any other’ as vascular (VAD) until proven otherwise – safely assess to determine need for referral
Higher Risk of VA Dissection in younger pt
Vascular dysfunction in neck should include consideration of Carotid artery dysfunction ➔ CAD has replaced VBI

Best practice – emphasis on good history taking & minimally provocative physical exam ➔ clinical reasoning