Week 3: Neck Pain Screening for Risk & Harm Flashcards
Cervical arteries
- Carotid
- Vertebral
How might cervical arteries get injured?
- Age related
- Traumatic, causing occlusion
What is the predominant symptoms of a stroke?
Pain in the neck
Which type of stroke should we be most aware of?
Vertebral artery, less common than those of the carotid artery
Reasons to suspect causation of a stroke by manipulation
- Can happen, but very rare
- If there is an increase of pain after the manipulation
- As the time b/t manipulation and stroke gets smaller, there’s greater reason to assume causality
Average risk level of adverse events after cervical manipulation
1 in ~ 2 million
Incidence of vertebral artery dissection causing stroke
0.97 per 100,000
Incidence of all strokes
269 per 100,000
Reasoned estimate of risk from chiropractic manipulation and stroke
1.3 per 100,000
There is an association b/t vertebrobasilar stroke and chiropractic visits in what age group?
<45 years old, but there is also a similar association b/t vertebrobasilar stroke and primary care physician visits in all age groups
What is a likely explanation for risk of vertebrobasilar stroke associated w/ visits to medical professionals?
There is dissection-related neck pain and headache prior to the visit
PTs routinely use cervical manipulation with patients who have:
- Neck pain
- Headache
- Dizziness
Risk for intervention: Cervical spine manipulation (low estimate)
- 0.005/10,000
- Potential complication: paralysis, stroke, death
Risk for intervention: Cervical spine manipulation (high estimate)
- 0.9/10,000
- Potential complication: paralysis, stroke, death
Risk for intervention: vigorous exercise
- 0.002/10,000
- Potential complication: Sudden death
Risk for intervention: NSAIDS
- 100-300/10,000
- Potential complication: GI bleed
Risk for intervention: NSAIDS w/ developed bleed
- 20/10,000
- Potential complication: Death
Nonischemic (local) symptoms of vertebral artery dissection
- Ipsilateral posterior neck pain/occipital headache
- C2-C6 cervical root impairment (rare)
- May precede cerebral/retinal ischemia by a few days-weeks
Ischemic symptoms of vertebral artery dissection
- Hind-brain TIE
- Hind-brain stroke (eg Wallenberg’s syndrome, locked-in syndrome)
Nonischemic (local) symptoms of carotid artery dissection
- Horner’s syndrome
- Pulsatile tinnitus
- Cranial nerve (CN) palsies (usually IX-XII)
Signs of Horner’s syndrome
- Ptosis
- Anhidrosis
- Miosis
Ptosis
Drooping of upper eyelid
Anhidrosis
Absence of sweating of the face
Miosis
Pupil constriction
Ischemic symptoms of carotid artery dissection
- Transient ischemic attack
- Ischemic stroke (usually middle cerebral artery territory)
- Retinal infarction
- Amaurosis fugax (temporary loss of vision in one or both eyes)
Components of the neurovascular physical exam
- Blood pressure
- BMI
- Pulse check
- Neuro exam
- Functional positional tests
- Ligamentous tests (upper cervical)
- Eye exam
Parts of the upper motor neuron screen
- Test for clonus
- Hoffman’s reflex
- Romberg test
- Babinski sign
Cranial nerve screen
See Week 2- Upper Quarter Screening Examination Flashcards
Guiding principles for screening for mobility during the cervical exam
- Incrementally increase movement and load
- Do not challenge the c-spine beyond what it would encounter during normal examination and treatment
What is the next step if there are no S/S of cervical artery dysfunction?
- Proceed with AROM testing
- Combined movement of extension w/ rotation
Ways to decrease risk with manual therapy for the neck
- Remember it’s not martial arts
- Pre-manipulative hold (see how the patient is handling the movement)
Risk factors for stroke
- BP
- Atrial fibrillation
- Smoking
- Cholesterol
- Diabetes
- Exercise
- Diet
- Stroke in family
Levels of risk for BP
- High: >140/90 or unknown
- Caution: 120-139/80-89
- Low: <120/80
Levels of risk for atrial fibrillation
- High: Irregular heart beat
- Caution: IDK
- Low: regular heartbeat
Levels of risk for smoking
- High: smoker
- Caution: trying to quit
- Low: nonsmoker
Levels of risk for cholesterol
- High: >240 or unknown
- Caution: 200-239
- Low: <200
Levels of risk for diabetes
- High: yes
- Caution: borderline
- Low: no
Levels of risk for exercise
- High: couch potato
- Caution: some exercise
- Low: regular exercise
Levels of risk for diet
- High: overweight
- Caution: slightly overweight
- Low: healthy weight
Levels of risk for hx of stroke in family
- High: yes
- Caution: not sure
- Low: no
Score results for stroke risk
- High risk: >/= 3 –> ask about prevention
- Caution: 4-6 –> reduce risk
- Low risk: 6-8 –> under control
Benefit/action of manual therapy for high risk of stroke
- Benefit: Low predicted benefit
- Action: Avoid treatment
Benefit/action of manual therapy for moderate risk of stroke
- Benefit: Moderate predicted benefit
- Action: Avoid/delay treatment –> monitor and reassess
Benefit/action of manual therapy for low risk of stroke
- Benefit: Low/mod/high benefit
- Action: Treat with care/monitor for change or new symptoms
Strategy for first visit with early onset neck pain
- Treat thoracic spine via manipulation and ROM
- Reassess 2nd visit
- Cervical mob/manip if appropriate
Timestamp for monitoring symptoms of neck pain
- During history
- During physical exam
- During intervention
- Prior to and after each phase of care
Emergency procedures for neck pain following manipulation
- DO NOT re-manipulate the neck
- Observe patient –> any transient S/S or cervicogenic proprioceptive dizziness?
- Call 911 (rescue and recovery position, record vitals, no food/drink, note time)
