The Monday Memo
January 14, 2018 PITT DPT STUDENTS
Clinical Assessment and Cervical Arterial Dysfunction
Cervical Arterial Dysfunction (CAD), although rare, is of vital consideration for any patient complaining of neck pain. As experts of the human movement system, physical therapists must recognize symptoms of non-musculoskeletal origin and refer accordingly. This is easier said than done in the case of CAD, as patient symptoms can often mimic the pain distribution of an occipital headache or general upper cervical dysfunction. To make matters worse, many clinical tests for CAD have little diagnostic utility in isolation. Therefore, the clinician must follow an efficient and thorough clinical process to make the best decision regarding patient care.
Taking a detailed patient history is critical in this process. The clinician should identify gaps in subjective data and clarify with the patient to ensure an accurate history is taken. Clinicians should also regularly assess basic vitals such as heart rate, respiratory rate, and blood pressure. Hypertension, when paired with other clinical findings, could be an indication of a vascular event. History of trauma that could lead to possible arterial dissection as well as congenital factors that may contribute to upper cervical dysfunction must be taken into consideration. Table 1 details clinical presentations at varying stages of CAD. The patient should be carefully assessed for these signs and symptoms prior to initiating further physical therapy assessment and intervention.
A. Rushton et al. provided a framework outlining the flow of clinical reasoning (Figure 1). The management of patients with suspected vascular compromise should be a decision derived from all components outlined in the chart as well as the patient’s response – or failure to respond – to previous assessment and intervention. Components of the physical exam may include but are not limited to upper cervical ligament testing, functional positional tests, assessment of upper motor neuron signs, and cranial nerve assessment.
In summary, there is no quick and easy assessment for patients with suspected cervical arterial dysfunction. The clinician must judiciously obtain the patient history, plan their examination, evaluate the individual’s presentation, and collaborate with the patient to appropriately manage their condition. As first-contact practitioners, physical therapists are likely to see patients whose chief complaint is head and/or neck pain. It is critical to identify all patient risk factors and initiate timely and appropriate treatment with a graded approach. By following this framework and applying one’s best clinical judgment, these patients may be safely managed.
-Joe Dietrich, SPT, ATC
Rushton A, et al., International framework for examination of the cervical region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy intervention, Manual Therapy (2013)
Kerry R, Taylor AJ. Cervical Arterial Dysfunction: Knowledge and Reasoning for Manual Physical Therapists. Journal of Orthopaedic & Sports Physical Therapy. 2009;39(5):378-387. doi:10.2519/jospt.2009.2926.