APA Clinical guide to safe manual therapy practice in the cervical spine 2017

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Introduction

Manual therapy can form an important instrument of the physiotherapy tool kit when managing patients with neck pain disorders. Although rare, the risk of catastrophic adverse effects has been associated with manual therapy of the cervical spine. The most serious associated adverse events include cervical artery dissection (CAD) and vertebrobasilar insufficiency (VBI), both of which can lead to stroke.

The purpose of this Australian Physiotherapy Association (APA) clinical guide is to assist physiotherapists to practice safe manual therapy within the cervical spine region with the awareness and knowledge to be able to manage the risks and recognise early warning signs of adverse events.

(i) Cervical Artery Dissection - CAD

CAD describes a tear, that can vary in severity, in the arterial wall of a main vessel that supplies blood to the brain. It is more common for CAD to effect the vertebral artery rather than the internal carotid however dissection in either can be fatal. Blood clots are often dislodged and travel to the brain causing cerebrovascular blockage.

Patient risk is increased with recent minor trauma, infection, genetic factors, migraine and cardiovascular risk factors. The patient demographic is usually under 55 years old and the pain pattern is a sudden onset of moderate to severe pain that does not subside. Therapists should be aware and ask patients about recent exposure to minor trauma (such as neck sprains or sporting injuries), recent unfamiliar neurological symptoms or recent infections.

Important early warning features of CAD to monitor your patient for are:

• sudden onset headache and/or neck pain
• unfamiliar and/or progressive neurological symptoms (5 Ds 3 Ns) D1 - Dizzyness/ unsteadiness N1 - Nystagmus D2 - Diplopia - double vision and/or visual field loss N2 - Nausea/vomiting D3 - Dysarthria/dysphasia N3 - Numbness/ parathesia (perioral) D4 - Dysphagia D5 - Drop attacks (sudden loss of consciousness)
• Horner's Sign
• Anything else about patient presentation that causes any clinical concern

(ii) VBI - Vertebrobasilar Insufficiency

VBI is associated with a patient group that are over 65 years old with cardiovascular risk factors such as hypertension and/or hypercholesterolemia and smoking history. However, it can be associated with CAD and occur at any age. The symptoms of VBI include dizziness and/ or unsteadiness, diplopia, dysarthria, dysphagia and sudden collapse without loss of consciousness (drop attacks). These symptoms are the result of inadequate blood supply reaching the hindbrain.

Positional testing can be performed to ascertain whether the patient is suspected to have VBI. If testing is positive, best practice is to treat within a range that does not provoke symptoms and avoid end of range neck positions during any therapy or exercises. Learn how to test - Vertebral Artery Testing.

The Guide

The clinical guide is summarised in the flow chart below defining the process of recognition and the optimal action plan for CAD and the 5 D's and 3 N's for VBI. These figures have been taken directly from the APA website.

The APA website is a great resource for all physiotherapists. This guide can be found on their website outlining the safe manual therapy practice when treating neck disorders.