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Benedetti P, McPhail W. Twist and Shout. Globe and Mail, June 14, 2008
Clinical Vignette # 1
20-year old female
Fell down stairs and hurt her back
Boyfriend suggested seeing his chiropractor
Over the next months 189 adjustments in 21
visits including upper cervical
Note: initial complaint was low back pain…
Clinical Vignette # 1
Rotary neck manipulation resulted in
inability to turn head
That night she kept walking into things at
work
Another visit to chiropractor next day
Clinical Vignette # 1
Neck adjustment
Patient immediately began to cry
Left eye rolled up, right roamed randomly
Convulsions
Clinical Vignette # 1
Turned blue, foaming at the mouth, did not
recognize her mother
Coma
Died next day from a traumatic rupture left
vertebral artery
Relevance to Physiotherapy?
With research evidence supporting its efficacy
physiotherapists routinely use cervical
manipulation in patients with:
Neck pain
Headache: Cervicogenic, tension-type, migraine
Dizziness: Cervicogenic
Douglass AB, Bope ET. Evaluation and treatment of posterior neck pain in family
practice. J Am Board Fam Pract 2004;17:S13-S22.
Guez M, et al. Chronic neck pain of traumatic and non-traumatic origin. Acta
Orthop Scand 2003;74:576-579
Epidemiology Headache
Cervicogenic headache: 0.4-2.5% in the general
population and up to 15-20% in those with chronic
headaches
Tension-type headache: Two-thirds of males and
over 80% of females in developed countries
Migraine headache: 1-year prevalence 6-8% in
males and 15-18% of females in Europe and US
World Health Organization. Headache Fact Sheet. 2008.
Haldeman S, Dagenais S. Cervicogenic headaches: A critical review. Spine J
2001;1:31-46
Epidemiology Dizziness
Dizziness accounts for 7% of physician visits for
patients over the age of 45
For adults over 65, it is the number one reason to
visit a physician
Approximately 15 to 30% of people experiencing
dizziness will seek medical attention
Graziano DL, Nitsch W, Huijbregts PA. Positive cervical artery testing in a patient
with chronic whiplash syndrome. J Manual Manipulative Ther 2007;15:E45-
E63
Manipulation, Dissection, and
Stroke?
Intima
Media
Adventitia
Anatomy: Artery
INTIMA
Layer of endothelial cells lining vessel interior
Rests on basal lamina
Turnover rate 1% per day
Sub-endothelial layer: longitudinally arranged
loose connective tissue and some smooth muscle
cells
In arteries: Internal elastic lamina, fenestrated
elastin allows diffusion to vessel wall
Anatomy: Artery
MEDIA
Concentric layers of helically arranged
smooth muscle cells
Variable amounts of elastic fibers and
lamellae, reticular fibers, and proteoglycans
In larger arteries: External elastic lamina
separating media from adventitia
Anatomy: Artery
ADVENTITIA
Longitudinally oriented Type I collagen and
elastic fibers
Gradually becomes continuous with
enveloping connective tissue
C1 (atlas)
Vertebral Artery
Internal Carotid Artery
C6
Anatomy: ICA
Provides 80% of blood flow to the brain
versus 20% supplied by the vertebrobasilar
system
Traverses sternocleidomastoid, longus
capitis, stylohyoid, omohyoid, and digastric
muscles
Anatomy: ICA
Fixed to the anterior aspect of the C1
vertebral body and in the carotid canal in
the petrous bone
Sustained rotation and extension-rotation
tests have also been proposed as tests of
ICA function
Current Emphasis on ICA:
Let’s Put This in Perspective
Biologically plausible
Proposed cause temporally related to
occurrence
Consistent across different samples and
groups
Positive correlation exposure and
occurrence
No other explanation
Bradford-Hill Criterion # 1:
Biological Plausibility
DiFabio RP. Manipulation of the cervical spine: Risks and benefits. Phys
Ther 1999;79:50-65
Evidence Linking Manipulation
to Stroke
Ernst (2002): Systematic review over 1995-2001
period
42 cases with serious adverse events: Mainly
arterial dissection
Also long thoracic nerve palsy, disk herniations,
myelopathy, epidural hematoma
Evidence Linking Manipulation
to Stroke
Insufficient data on type of manipulation used
Underreporting bias?
Manipulation
Whiplash
Direct Vessel Trauma:
Whiplash
In a retrospective analysis, Beaudry and
Spence attributed 70 of 80 traumatically
induced cases of vertebrobasilar ischaemia
to motor-vehicle accidents
Beaudry M, Spence JD. Motor vehicle accidents: The most common cause
of traumatic vertebrobasilar ischaemia. Can J Neurol Sci 2003;30:320-
325
Whiplash and Dizziness
Dizziness, vertigo, and dysequilibrium are
symptoms in 20-58% of individuals that
have sustained a whiplash-type injury of the
cervical spine or a closed head injury
Grimm RJ. Inner ear injuries in whiplash. J Whiplash Rel Disord 2002:1:65-75;
Oostendorp RAB, et al. Dizziness following whiplash injury: A neuro-otological study
in manual therapy practice and therapeutic implication. J Manual Manipulative Ther
1999;7:123-130
Not all Dizziness Implies CAD
Rubinstein SM, et al. A systematic review of the risk factors for cervical
artery dissection. Stroke 2005;36:1575-1580
So Where Does This Leave
Us?
Presenting complaint provides no relevant
information
Clinically relevant risk factors: Previous
medical history of treatment with cervical
manual therapy interventions, hypertension,
previous infection, and migraine headache
Questionable risk factors: Atherosclerosis,
thyroid disease, and arteriopathies…
Physical Examination?
De Kleyn-Nieuwenhuyse Test
In 1927, De Kleyn and Nieuwenhuyse
reported decreased or even absent vertebral
artery blood flow based on cadaver
perfusion studies in different head and neck
positions
De Kleyn-Nieuwenhuyse Test
Based on these anatomical observations and these
early perfusion studies, the sustained extension-
rotation and the sustained rotation tests have been
proposed and widely instructed and used as tests
to determine the presence of vertebrobasilar artery
dysfunction
Ipsilateral
carotid bruit
Neck swelling
Scalp tenderness
Anhydrosis face
Ischaemic Signs and
Symptoms ICA
TIA
Middle cerebral artery distribution stroke
Retinal infarction
Amaurosis fugax: Temporary blindness
Local patchy blurring of vision: Scintillating
scotomata
Weakness extra-ocular muscles
Protrusion eye
Swelling eye or conjunctiva
Horner syndrome
Carotid Bruit
56% sensitivity and 91% specificity for detection
of a 70-99% carotid stenosis when compared with
color duplex ultrasound
Implication?
Cervicogenic headache
Tension-type headache
Migraine headache
Cervicogenic Headache
Pain, referred from a source in the neck and
perceived in one or more regions of the head
and/or face, fulfilling criteria C and D
Clinical, laboratory and/or imaging evidence of a
disorder or lesion within the cervical spine or
soft tissues of the neck known to be, or generally
accepted as, a valid cause of headache
Cervicogenic Headache
Evidence that the pain can be attributed to the neck
disorder or lesion based on at least one of the
following:
1. Demonstration of clinical signs that implicate a
source of pain in the neck
2. Abolition of headache following diagnostic
blockade of a cervical structure or its nerve
supply using placebo- or other adequate controls
Pain resolves within 3 months after successful
treatment of the causative disorder or lesion
Referral Pattern Upper
Trapezius Muscle
Referral Pattern Levator
Scapulae Muscle
Referral Pattern
Sternocleidomastoid Muscle
Referral Pattern Temporalis
Muscle
Referral Patterns Splenius Capitis
(Left) and Cervicis (Right) Muscles
Referral Patterns Semispinalis
Cervicis (Left) and Capitis (Right)
Muscles
Tension-Type Headache
Hypothesized to be related to myofascial trigger
points
Prolonged nociceptive input may lead to central
sensitization
Amplification of receptiveness of central pain-
signaling neurons to input from low-threshold
mechanoreceptors
Clinically characterized by the presence of
hyperalgesia and/or allodynia
Tension-Type Headache
Headache has at least two of the following characteristics:
1. Bilateral location
2. Pressing/tightening (non-pulsating) quality
3. Mild to moderate intensity
4. Not aggravated by routine physical activity such as
walking or climbing stairs
Both of the following:
1. No more than one of photophobia, phonophobia or mild
nausea
2. Neither moderate or severe nausea nor vomiting
Not attributed to another disorder
Migraine with Aura
At least 2 attacks fulfilling criteria 2-4
Aura consisting of at least one of the following,
but no motor weakness:
1. Fully reversible visual symptoms including
positive features (e.g., flickering lights, spots or
lines) and/or negative features (i.e., loss of vision)
2. Fully reversible sensory symptoms including
positive features (i.e., pins and needles, peri-oral
paraesthesiae) and/or negative features (i.e.,
numbness)
3. Fully reversible dysphasic speech disturbance
Migraine with Aura
At least two of the following:
1. Homonymous visual symptoms and/or
unilateral sensory symptoms
2. At least one aura symptom develops gradually
over ≥5 minutes and/or different aura symptoms
occur in succession over ≥5 minutes
3. Each symptom lasts ≥5 and ≤60 minutes
Headache fulfilling criteria Migraine without aura
begins during the aura or follows aura within 60
minutes
Not attributed to another disorder
CPR Migraine Headache
Diagnosis
Five questions:
1. Is it a pulsating headache
2. Does it last between 4 and 72 hours
without medication?
3. Is it unilateral?
4. Is there nausea
5. Is the headache disabling (disrupting daily
activities)?
CPR Migraine Headache
Diagnosis
≥ 4 questions yes: LR+ 24 (95% CI: 1.5-
388)
3 questions yes: LR+ 3.5 (95% CI: 1.3-9.2)
1 or 2 questions yes: LR+ 0.41 (95% CI:
0.32-0.52)
Mnemonic POUNDing: Pulsating, Duration
of 4-72 hours, Unilateral, Nausea, Disabling
Relevance thunderclap
headache
In 27 cases of non-CSMT VAD this headache
preceded the neurological symptoms:
By less than 1 day in < 30% of cases
By 1-3 days in 15%
By 1-2 weeks in 30%
By > 3 weeks in 25%
Manipulation or mobilization
Type of manipulative technique
Upper versus lower cervical techniques
Mobilization or Manipulation?
Michaeli (1993): Questionnaire sent to
manipulative physiotherapists in South
Africa
228,050 procedures
Only minor adverse effects reported for
manipulation
29 patients receiving cervical spinal
manipulation reported 52 complications
Mobilization or Manipulation?
However:
58 patients receiving spinal mobilization to the
cervical spine reported 129 complications
One mobilization patient suffered a CVA
Implication for risk reduction?
Mas JL, et al. Extracranial vertebral artery dissections: A review of 13 cases. Stroke
1987;18:1037-1047
Mokri B, et al. Spontaneous dissections of the vertebral arteries. Neurology 1988;38:880-
885
Saeed AB, et al. Vertebral artery dissection: Warning symptoms, clinical features, and
prognosis in 26 patients. Can J Neurol Sci 2000;27:292-296.
Manipulation: Effect of Level?
Cervical manipulation definable event with
evidence of a mechanical effect
Provided and recorded by third parties unlike
etiologic mechanisms such as shoulder checking,
hair washing, etc.
“Not to say less recordable mechanical events are
less related to dissection”
Kawchuk GN, et al. The relationship between the spatial distribution of vertebral artery
compromise and exposure to cervical manipulation. J Neurol 2008;255:371-377.
Manipulation: Effect of Level?
Populations studied
5-year retrospective review yielding a cohort of 25
patients with VA dissection not related to major
trauma or CSMT from Foothills Hospital, Calgary,
AB
26 of 64 cases reported by Haldeman et al from
retrospective case review article
Diagnostic imaging or reports had to be available
to determine location of VA dissection
Manipulation: Effect of Level?
V3 segment most commonly dissected
Prevalence ratio (PR) V3 versus V1
prevalence in CSMT group = 8.46 (95%
CI: 3.53-20.24)
PR V3 versus V1 in non-CSMT group =
4.00 (95% CI: 1.43-11.15)
Manipulation: Effect of Level?
Note: Higher prevalence irrespective of exposure
to CSMT
“Demonstrates the impact of everyday movements
and postures [on this mechanically more
vulnerable segment]”
Age and gender not found to be significant factors
But: V3 vulnerability augmented by CSMT
exposure
Manipulation: Effect of Level?
However, multiple site lesions also
significantly more common in both groups
CSMT: PR = 2.67 (95% CI: 1.98-3.58)
No CSMT: PR = 2.44 (95% CI: 1.81-3.29)
Interpretation?
Manipulation: Effect of Level?
Report of compression at C6 secondary
to osteophyte arising from superior
facet C6
Any questions?