Vascular Pathologies of the Neck: Difference between revisions
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== Definition/Description == | == Definition/Description == | ||
== Cervical arterial dysfunction (CAD) is an umbrella term used in manual therapy and physiotherapy to cover a range of vascular pathologies which may lead to cervico-cranial ischaemia. CAD is inclusive of all known vascular pathologies and anatomical structures that may be compromised by movement or manual therapy. Further, the clinical model of CAD incorporates the notion of assessing for patients presenting to physiotherapists with neuromusculoskeletal neck and head pain who may have an increased risk of developing an associated pathology. Thus the model has two dimensions: first, to identify underlying vascular pathologies masquerading as neuromusculoskeletal pain; second, to identify the risk of developing arterial pathology during assessment or intervention. The term was first described in 2008 (1) and has been adopted by the International Federation of Orthopaedic Manual Physical Therapists (IFOMPT) in their 2013 document: | |||
‘International framework for examination of the cervical region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy intervention’ (2) | |||
The IFOMPT document provides clinical reasoning and physical examination guidance for clinicians and highlights the need for manual therapy clinicians to be cognisant with the concept and details of CAD. Much of the information on this page is detailed further in the IFOMPT document. | |||
Note: The term should not be confused with cervical arterial dissection which is also referred to via the acronym CAD. This relates to a single, specific pathology (see below). | |||
CAD itself is not a specific pathology diagnosis. Thus, there is a variation in clinical presentation which is dependent on the structure involved, the pathological mechanism and the stage at which the dysfunction presents. CAD is of relevance to clinicians due to the fact the pain is often an early presentation of many types of arterial dysfunction, Fig 1. Later ischaemic manifestations of CAD, such as cranial nerve dysfunction and brain ischemia, may be latent and develop hours, days or weeks after onset. Table 1 (below) details the range of presentations and associated clinical symptoms<br> | |||
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== Clinically Relevant Anatomy<br> == | == Clinically Relevant Anatomy<br> == | ||
Revision as of 17:32, 17 January 2014
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Definition/Description[edit | edit source]
== Cervical arterial dysfunction (CAD) is an umbrella term used in manual therapy and physiotherapy to cover a range of vascular pathologies which may lead to cervico-cranial ischaemia. CAD is inclusive of all known vascular pathologies and anatomical structures that may be compromised by movement or manual therapy. Further, the clinical model of CAD incorporates the notion of assessing for patients presenting to physiotherapists with neuromusculoskeletal neck and head pain who may have an increased risk of developing an associated pathology. Thus the model has two dimensions: first, to identify underlying vascular pathologies masquerading as neuromusculoskeletal pain; second, to identify the risk of developing arterial pathology during assessment or intervention. The term was first described in 2008 (1) and has been adopted by the International Federation of Orthopaedic Manual Physical Therapists (IFOMPT) in their 2013 document: ‘International framework for examination of the cervical region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy intervention’ (2)
The IFOMPT document provides clinical reasoning and physical examination guidance for clinicians and highlights the need for manual therapy clinicians to be cognisant with the concept and details of CAD. Much of the information on this page is detailed further in the IFOMPT document.
Note: The term should not be confused with cervical arterial dissection which is also referred to via the acronym CAD. This relates to a single, specific pathology (see below).
CAD itself is not a specific pathology diagnosis. Thus, there is a variation in clinical presentation which is dependent on the structure involved, the pathological mechanism and the stage at which the dysfunction presents. CAD is of relevance to clinicians due to the fact the pain is often an early presentation of many types of arterial dysfunction, Fig 1. Later ischaemic manifestations of CAD, such as cranial nerve dysfunction and brain ischemia, may be latent and develop hours, days or weeks after onset. Table 1 (below) details the range of presentations and associated clinical symptoms
==
Clinically Relevant Anatomy
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add text here relating to clinically relevant anatomy of the condition
Epidemiology/Etiology[edit | edit source]
Mechanism of Injury / Pathological Process
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Risk Factors[edit | edit source]
The following risk factors are associated with an increased risk of either internal carotid or vertebrobasilar arterial pathology and should be thoroughly assessed during the patient history[1][2]:
- Past history of trauma to cervical spine / cervical vessels
- History of migraine-type headache
- Hypertension
- Hypercholesterolemia / hyperlipidemia
- Cardiac disease, vascular disease, previous cerebrovascular accident or transient ischaemic attack
- Diabetes mellitus
- Blood clotting disorders / alterations in blood properties (e.g. hyperhomocysteinemia)
- Anticoagulant therapy
- Long-term use of steroids
- History of smoking
- Recent infection
- Immediately post partum
- Trivial head or neck trauma[3][4]
- Absence of a plausible mechanical explanation for the patient’s symptoms.
Clinical Presentation[edit | edit source]
- Head and neck pain
- 5D's And 3N's
- Dizziness
- Drop attacks
- Diplopia
- Dysarthria
- Dysphagia
- Ataxia
- Anxiety
- Nausea
- Numbness
- Nystagmus
Examination[edit | edit source]
The International Framework for Examination of the Cervical Region disucsses several techniques to assess for CAD:
- Blood Pressure
- Craniovertebral ligament testing
- Neurological examination
- Positional testing
- Palpation of the carotid artery
Importance of observation throughout history[edit | edit source]
Signs and symptoms of serious pathology and contraindications / precautions to treatment may manifest during the patient history stage of assessment. This is an opportunity to observe and recognise possible red flag indicators such as gait disturbances, subtle signs of disequilibrium, upper motor neuron signs, cranial nerve dysfunction, and behaviour suggestive of upper cervical instability (e.g. anxiety, supporting head/neck) early in the clinical encounter.
Differential Diagnosis[edit | edit source]
The following information is provided to assist in the differential diagnosis of musculoskeletal dysfunction from serious pathologies which commonly manifest as musculoskeletal dysfunction[1][5][2][6]:
| Internal carotid artery disease | Vertebrobasilar artery disease | Upper cervical instability | |
|---|---|---|---|
| Early presentation | Mid-upper cervical pain, pain around ear and jaw (carotidynia), head pain (fronto-temporo-parietal); Ptosis; Lower cranial nerve dysfunction (VIII-XII); Acute onset of pain described as "unlike any other”. |
Mid-upper cervical pain; occipital headache; Acute onset of pain described as "unlike any other”. |
Neck and head pain; Feeling of instability; Cervical muscle hyperactivity; Constant support needed for head; Worsening symptoms. |
| Late presentation | Transient retinal dysfunction (scintillating scotoma, amaurosis fugax); Transient ischaemic attack; Cerebrovascular accident. |
Hindbrain transient ischaemic attack (dizziness, diplopia, dysarthria, dysphagia, drop attacks, nausea, nystagmus, facial numbness, ataxia, vomiting, hoarseness, loss of short term memory, vagueness, hypotonia/limb weakness [arm or leg], anhidrosis [lack of facial sweating], hearing disturbances, malaise, perioral dysthaesia, photophobia, papillary changes, clumsiness and agitation); Cranial nerve dysfunction; Hindbrain stroke (e.g. Wallenberg’s syndrome, locked-in syndrome). |
Bilateral foot and hand dysthaesia; Feeling of lump in throat; Metallic taste in mouth (VII); Arm and leg weakness; Lack of coordination bilaterally. |
It is important to consider the above information in the context of the aforementioned risk factors.
Outcome Measures[edit | edit source]
add links to outcome measures here (see Outcome Measures Database)
Management / Interventions
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add text here relating to management approaches to the condition
Differential Diagnosis
[edit | edit source]
add text here relating to the differential diagnosis of this condition
Key Evidence[edit | edit source]
add text here relating to key evidence with regards to any of the above headings
Resources
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add appropriate resources here
Case Studies[edit | edit source]
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Recent Related Research (from Pubmed)[edit | edit source]
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References[edit | edit source]
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- ↑ 1.0 1.1 Arnold M, Bousser MG (2005). Carotid and vertebral dissection. Practical Neurology 5:100-109.
- ↑ 2.0 2.1 Kerry R, Taylor AJ, Mitchell JM, et al (2008). Cervical arterial dysfunction and manual therapy: A critical literature review to inform professional practice. Manual Therapy 13(4):278-288.
- ↑ Haneline M, Lewkovich G (2004). Identification of internal carotid artery dissection in chiropractic practice. J Can Chiropr Assoc 48(3):206-10.
- ↑ Thomas LC, Rivett DA, Attia JR, et al (2011). Risk factors and clinical features of craniocervical arterial dissection. Manual Therapy 16(4):351-356.
- ↑ Arnold M, Bousser G, Fahrni G, et al (2006). Vertebral Artery Dissection Presenting Findings and Predictors of Outcome. Stroke 37:2499-2503.
- ↑ Kerry R (2011). Examination of the Upper Cervical Region, Chapter 6, in: Petty NJ (Ed), Neuromusculoskeletal examination and assessment: a handbook for therapists, 4th Edn. Churchill Livingstone, Elsevier, Edinburgh.
