Section 3: Patient history

Clinical reasoning processes

In line with the emphasis on clinical reasoning, it is essential that the patient history is used to establish and test hypotheses related to potential adverse events of OMT. It is important to understand that there are very limited diagnostic utility data related to many factors considered here. Therefore, the physical therapist’s aim during the patient history is to make the best judgment on the probability of serious pathology and contraindications to treatment based on available information.

Many red flags which contraindicate or limit OMT treatment manifest in an obvious way in the patient presentation (Moore et al 2005), such as:

Contraindications to OMT interventions:

• Multi-level nerve root pathology
• Worsening neurological function
• Unremitting, severe, non-mechanical pain
• Unremitting night pain (preventing patient from falling asleep)
• Relevant recent trauma
• Upper motor neuron lesions
• Spinal cord damage
• And the features detailed in section 3.4

Precautions to OMT interventions:

• Local infection
• Inflammatory disease
• Active cancer
• History of cancer
• Long-term steroid use
• Osteoporosis
• Systemically unwell
• Hypermobility syndromes
• Connective tissue disease
• A first sudden episode before age 18 or after age 55
• Cervical anomalies
• Throat infections in children
• Recent manipulation by another health professional

However, there are serious conditions which may mimic musculoskeletal dysfunction in the early stages of their pathological progression:

• CAD (e.g. vertebrobasilar insufficiency due to dissection) (Kerry et al, 2008)
• Upper cervical instability (Niere and Torney, 2004), that could compromise the vascular and neurological structures.

A patient experiencing, for example pain from one of these presentations may seek OMT for the relief of the pain (Murphy, 2010; Taylor and Kerry, 2010). It is therefore important that the subtle symptoms of these pathologies are recognised in the patient history. It is also important to recognise risk factors indicating a potential for neuro-vascular pathology. Information is given below to highlight the key components of the patient history in this context.

Risk factors

Cervical arterial dysfunction

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 (Arnold and Bousser, 2005; Kerry et al, 2008):

• 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 (Haneline and Lewkovich, 2005; Thomas et al, 2011)
• Absence of a plausible mechanical explanation for the patient’s symptoms.

Upper cervical instability

The following risk factors are associated with the potential for bony or ligamentous compromise of the upper cervical spine (Cook et al 2005):

• History of trauma (e.g. whiplash, rugby neck injury)
• Throat infection
• Congenital collagenous compromise (e.g. syndromes: Down’s, Ehlers-Danlos, Grisel, Morquio)
• Inflammatory arthritides (e.g. rheumatoid arthritis, ankylosing spondylitis)
• Recent neck/head/dental surgery.

Importance of observation throughout history

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.

Differentiation

The following information is provided to assist in the differential diagnosis of musculoskeletal dysfunction from serious pathologies which commonly manifest as musculoskeletal dysfunction (Arnold and Bousser, 2005; Arnold et al, 2006; Kerry et al, 2008; Kerry, 2011):

Differential diagnosis

		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.

Typical case histories of vascular dysfunction

Common vertebral artery dissection

Case:

A 46 year-old female supermarket worker presented to physical therapy with left-sided head (occipital) and neck pain described as “unusual”. She reported a 6 day history of the symptoms following a road traffic accident. The symptoms were progressively worsening. The pain was eased by rest. She reported a history of previous road traffic accidents. Past medical history included hypertension, high cholesterol, and a maternal family history of heart disease and stroke. Cranial nerve tests for VIII, IX, and X were positive and resting blood pressure was 170/110. Two days after assessment, the patient reported an onset of new symptoms including “feels like might be sick”, “throaty” and “feels faint” – especially after performing prescribed neck exercises. Two days after this, she reported a stronger feeling of nausea, loss of balance, swallowing difficulties, speech difficulties and acute loss of memory. Magnetic resonance arteriography revealed an acute hindbrain stroke related to a left vertebral (extra-cranial) artery dissection.

Synopsis:

A typical background of vascular risk factors and trauma, together with a classic pain distribution for vertebral arterial somatic pain which was worsening. Positive signs (blood pressure and cranial nerve dysfunction) were suggestive of cervical vascular pathology. Signs of hindbrain ischaemia developed in a typical time period post-trauma.

Vertebral artery with pain as the only clinical feature

Case: A friend presents to a physical therapist with a sore neck and unremitting headache. The individual complains that they “think” their “neck is out”. They ask if they can have their neck manipulated to “put it back in”. The headache has been present for 3-4 days and is getting worse. They note that the pain has been unrelieved by medication (paracetamol) and it appears to be of a mechanical presentation. Without taking a full history and carrying out a physical examination, the physical therapist goes ahead and manipulates the neck. The result was the individual experiencing numbness and paralysis to their left arm and hand.

Synopsis: Investigation post incident identified an intimal tear of the vertebral artery. The key issue in this case is that the presentation was not fully assessed through a detailed history and physical examination. The warning feature from the history of worsening pain, unrelieved by medication, combined with an inadequate physical examination and limited clinical reasoning, all contributed to an unfortunate and probably avoidable outcome.

Internal carotid artery dissection

Case: A 42 year-old accountant presents to physical therapy with a 5 day history of unilateral neck and jaw pain, as well as temporal headache, following a rear-end motor vehicle collision. There is a movement restriction of the neck and the physical therapist begins to treat with gentle passive joint mobilisations, and advises range of movement exercises. The following day, the patient’s pain is worse, and he has developed an ipsilateral ptosis. The patient’s blood pressure is unusually high.

Synopsis: On medical investigation, an extra-cranial dissection of the internal carotid artery was found. The patient had underlying risk factors for arterial disease, and the presentation was typical of internal carotid artery dissection, with a key differentiator being the ptosis. A dramatic systemic blood pressure response was a result of this vascular insult.

Further examples of similar cases can be found in the literature

(Biousse et al, 1994; Lemesle et al, 1998; Crum et al, 2000; Zetterling et al, 2000; Chan et al, 2001; Caplan and Biousse, 2004; Arnold and Bousser, 2005; Asavasopon et al, 2005; Rogalewski and Evers, 2005; Taylor and Kerry, 2005; Thanvi et al, 2005; Arnold et al, 2006; Debette and Leys, 2009; Kerry and Taylor, 2009).

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