1. Simplifying Cervical Spine Red Flags Cervical Artery Dysfunction

2. Red Flags Red Flags are signs and symptoms of a potentially serious pathology Red Flags are a contraindication to many forms of manual therapy What else do they contraindicate? Exercise Objective Assessment Many court cases due to vascular accidents after physiotherapy are NOT due to manipulation

3. Red Flags- Subjective The 5D’s and 3N’s of Coman are commonly discussed: These symptoms of a Hind-brain Transient Ischaemic Attack Are we likely to see these people in our clinics? D’sN’sA’s DizzinessNauseaAtaxia Dysarthria (talking)Nystagmus (eyes flicking) Dysphagia (swallowing)Numbness (of face) Diplopia (double vision) Drop Attacks

4. Red Flags 5D’s and 3N’s are Red Flags BUT If someone presents with these symptoms is it too late? Cervical Spine Red Flags can indicate many different pathologies… One commonly discussed is Cervical Artery Dysfunction (although rarely present) Someone may have Cervical Artery Dysfunction but not present with ANY of the 5D’s or 3N’s…

5. Cervical Artery Dysfunction (CAD) CAD is a description – NOT a diagnosis CAD is pathology to the arteries in the neck NOT Vertebrobasilar Insufficiency (VBI) = old terminology Two vascular systems Anterior (Internal Carotid) Posterior (Vertebro-basilar) Dysfunction can occur in either or both systems Dysfunction can be ischemic (lack of blood supply to brain) OR non-ischemic (local, somatic causes) Non-ischemic signs can precede ischemic signs by a few days or weeks CAD can simply present as ‘neck pain’ without other signs Arteries have nociceptors

6. D is for Dysfunction ‘Dysfunction’ does not always mean a ‘Dissection’ Some pathologies that can alter blood flow or haemodynamics are: Arteritis Atherosclerotic disease Vasospasm Underlying anatomical anomalies Dissection These pathologies can lead to CAD (McCarthy, 2012)

7. Internal Carotid Artery Anterior system Supplies 80% of blood supply to the brain Arises from the common carotid artery at approximately C3 and is tethered to body of C1 Supplies ipsilateral cerebral hemisphere, the eye and accessory organs, the forehead and part of the nose Cervical extension can restrict blood flow (Taylor & Kerry, 2010)

8. Internal Carotid Artery Dysfunction Non-Ischemic Signs Horner’s Syndrome- 82% of cases Dropping eyelid (ptosis) Sunken eye (enophthalmia) Small constricted pupil (miosis) Facial Dryness (anhidrosis) The superior cervical sympathetic ganglion supplying the eye are found in the carotid sheath and follow the course of the carotid artery (Bilky, 2012)

9. Internal Carotid Artery Dysfunction Non-Ischemic Signs Lower Cranial Nerve Dysfunction (IX – XII) Glossopharyngeal (Palate Elevation and Gag Reflex) Vagus (Palate Elevation and Gag Reflex) Accessory (Resisted Cervical Rotation and Shoulder Shrug) Hypoglossal (Stick Tongue out and into sides of mouth) Acute onset head or neck pain like no other Ipsilateral neck and facial pain (Taylor & Kerry, 2010)

10. Internal Carotid Artery Dysfunction Ischemic Signs Signs of Cerebral Stroke or Retinal Ischemia Transient Ischemic Attack Ischemic Stroke Retinal Ischemia Painless episodic loss of vision Localized/patchy blurring of vision Weakness of eye muscles Protrusion of eye Swelling of the eye Unlikely to present in a physiotherapy clinic, however be aware of Retinal Ischemic changes

11. Vertebro-basilar Artery Posterior system Supplies 20% of the blood supply to the brain Passes through each foramen transversarium except C7 Artery has a ‘kink’ within it as it right angles around the lateral mass of atlas, and then right angles into the foramen magnum Vulnerable to internal and external factors to compromise blood flow at these two right angled bends Contralateral rotation can restrict blood flow (Magee, 2008)

12. Vertebral Artery Dysfunction Non-Ischemic Signs Ipsilateral posterior neck pain and occipital headaches C5/6 Nerve root impairment (rare) Weakness Wrist Extension Weakness Elbow Flexion Sensation change thumb side hand, wrist and forearm (Taylor & Kerry, 2010)

13. Vertebral Artery Dysfunction Ischemic Signs 5D’s and 3N’s Ataxia Vomiting Vascular Dizziness is very common with Vertebral artery dysfunctions Does not improve with repeated rotations

14. Risk Factors For CAD Underlying pathology which weakens the blood vessels Mechanical forces that can alter haemodynamics Trauma Hypertension Hypercholesterole mia Hyperlipidemia Diabetes Mellitus Infections Genetic clotting disorders Smoking Family History of Vascular Pathology or Early Strokes (Pai and Kloner 2014)

15. The Assessment Process

16. Red Herrings, Red Flags and Neurological Signs Many people with neck pain may present with neurological signs Don’t panic! Peripheral sensory, motor and reflex changes in isolation are not “Red Flags” Likewise isolated “Red Flags” do not necessarily indicate serious pathology “Red Flags” occurring in combination, or neurological signs that persist or worsen increases the likelihood of serious pathology Keep calm, at the end of the subjective, question yourself: “Is this person presenting with a serious pathology?”

17. Red Flags & CAD - Subjectively Clear 5D’s and 3N’s as normal however unlikely to present in clinic (other than Dizziness) Ask further questions related to cranial nerves Detailed PMH and FH Clinical Reasoning! At the end of the subjective think “Does this person have subjective symptoms suggestive of serious pathology?”

18. Red Flags & CAD - Objectively Potential Red Flags massively affect the order of your objective examination Diagnostic Medical Work Up Blood Pressure Cranial Nerve Testing Active ROM Passive ROM Never continue the examination if you suspect serious pathology is present (or if you do not possess the skills to perform relevant examinations - e.g cranial nerves, Blood Pressure) Always REFER ON when necessary to the appropriate practitioner

19. Key Learning Points Red Flags are incredibly rare Red Flags do not contraindicate Manual Therapy alone, ALSO Exercise and Objective examination techniques CAD most likely to be found in physiotherapy clinics but can mask itself as MSK pain 5D’s and 3N’s are not sufficient enough to rule out CAD Detailed subjective history including PMH and FH helps support ruling in or out CAD Tailor Objective to RULE OUT pathology Including BP and Cranial Nerve Testing if trained to do so REFER ON when you suspect serious pathology Rapidly changing area of physiotherapy…

20. Cervical Spine – Simplified 1.Rule out any Cervical Red Flags 2.Complete Structured Objective Assessment 3.Devise a Problem List 4.Treat: Do some talking therapy Do some hands on therapy Do some exercise therapy 5.Refer on where necessary

21. Further Reading Kerry, R. and A. J. Taylor (2006). "Cervical arterial dysfunction assessment and manual therapy." Man Ther 11(4): 243-253. Kerry, R. and A. J. Taylor (2009). "Cervical arterial dysfunction: knowledge and reasoning for manual physical therapists." J Orthop Sports Phys Ther 39(5): 378-387. Kerry, R., A. J. Taylor, J. Mitchell and C. McCarthy (2008). "Cervical arterial dysfunction and manual therapy: a critical literature review to inform professional practice." Man Ther 13(4): 278-288. Rushton, A., D. Rivett, L. Carlesso, T. Flynn, W. Hing and R. Kerry (2014). "International framework for examination of the cervical region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy intervention." Man Ther 19(3): 222-228. Taylor, A. J. and R. Kerry (2005). "Neck pain and headache as a result of internal carotid artery dissection: implications for manual therapists." Man Ther 10(1): 73-77. Taylor, A. J. and R. Kerry (2010). "A ‘system based’ approach to risk assessment of the cervical spine prior to manual therapy." International Journal of Osteopathic Medicine 13(3): 85-93. Taylor, A. J. and R. Kerry (2013). "Vascular profiling: should manual therapists take blood pressure?" Man Ther 18(4): 351-353.

22. References Bilky, J. (2012). "How to spot and treat dangerous ptosis." Retrieved May, 2014, from http://www.reviewofophthalmology.com/content/d/plastic_pointers/c/32 801/. http://www.reviewofophthalmology.com/content/d/plastic_pointers/c/32 801/ Magee, D. J. (2008). Orthopedic Physical Assessment, Saunders Elsevier. McCarthy, C. (2012). Combined Movement Theory: Rational Mobilization and Manipulation of the Vertebral Column, Elsevier Health Sciences UK. Pai, R. and R. Kloner. (2014). "Atherosclerosis." Heart Disease Health Center Retrieved May, 2014, from http://www.webmd.com/heart- disease/atherosclerosis-19012.http://www.webmd.com/heart- disease/atherosclerosis-19012 Taylor, A. J. and R. Kerry (2010). "A ‘system based’ approach to risk assessment of the cervical spine prior to manual therapy." International Journal of Osteopathic Medicine 13(3): 85-93.