You receive a call from your friend and fellow DPT classmate to evaluate her neck… the patient herself is a physical therapist by occupation. A healthy and fit 29 year old female, 5’0″, 115lbs. She reports she is having some cervical musculoskeletal issues going on. She has an achy pain in the bilateral upper traps., levator scapula, and peri-cervical muscles. She is limited by pain with the following cervical motions: right side-bend, right rotation and extension. No signs of central or peripheral neurological issues.
You are an experienced PT and have completed many cervical manipulations on a patient like this and it’s the end of your day. So you are going to do a quick favor for a friend and manipulate her neck, complete some STM, and maybe some PROM/SNAGs/isometrics/METs or whatever your favorite manual therapy technique is. What could go wrong? She’s a therapist herself so she wouldn’t miss anything serious. Being that you are friends you want to do some “magic” giving her some relief of symptoms. So… snap, crackle, manip. You move into some PROM and she reports severe vertigo, nausea, double vision, and you notice hemi-facial asymmetries as she talks about her onset of symptoms. Now what? Your table, your hands, your patient.
Okay, maybe that’s not how this case study ended… however everything up to performing the manipulation is accurate. If it wasn’t for a diligent physical therapist she very well could have ruined the friendship and in this case killed her, which would be biologically plausible.
The 29 year-old patient returns from an Alaskan vacation in June, 2011. This patient began to experience a dull ache behind her right eye which mimicked a typical headache that she has experienced prior. 4 weeks later, in July, she continued to have the pain but it was getting progressively worse, and now she experiences hemi-facial pain which corresponds with the intensity of her headache. As the headache increased, facial pain increased. She treated herself with Advil and various OTC medications.
Throughout the month of August, 2011 she checked herself into the ER due to a 9/10 pain in the right cervical region. The results for her four ER visits are as follows: 1) Brain CT Scan (-), 2) Brain MRI (-), 3) Brain MRV (-), 4) Brain MRA (-)… 4 times cleared by the emergency department and told it’s progressive migraines, please manage them with medications. The patient returns home very frustrated, exhausted due to lack of sleep from pain and now in what is a more consistent pain varying 5/10 to 9/10. The patient made an appointment with an Ophthalmologist due to the continued ache behind her right eye. Ophthalmologist’s diagnosis is a bad case of “twisted eye muscles” … huh? Yeah I’m serious. No joke. Patient continues to move along the health system (which is failing her) and is fed up. It’s now September 26th, 2011 and she now has sore traps and levator, peri-cervical and peri-scapular muscular pain, and she really would like some quick pain relief. Doesn’t matter if it’s short-term effects, she just needs some effect.
So.. who else will give her pain relief but that good friend and fellow physical therapist? The patient calls her friend and asks to be seen by her, even requesting manual therapy work to her cervical spine.
At this point the reader should take off his or her shoes and put on the shoes of the patient’s friend. Your friend was cleared by the ER 4 times with 4 negative image reports, was cleared by an ophthalmologist, and is a physical therapist herself. What could go wrong?
Patient walks into the clinic and the evaluation begins, as it should no matter who it is:
- Direct Access Physical Therapy Visit
- 29 y/o, female, 5’0”, 115lbs
- Chief Complaint
- Hemi-Facial Pain
- Right cervical and shoulder pain
- R sided Headache
- Right Orbital Pain
- Tender to Nuchal Ligament, R Upper Trapezius, R Temple Region, R Cervical Extensors
- 5/5 Myotome UE, C-Spine not tested due to pain
- 2+ bilaterally and Equal biceps, triceps, brachioradialis
- Hoffman Test: Negative
- Cervical ROM
- R rotation, R SideBend, and Extension 75% limited
- Shoulder ROM: WNL Bilaterally
- Intact to light touch, Sharp/Dull, and Hot/Cold on Face and Upper Extremity
- Cranial Nerve Test
- All Normal
Due to the repetitive diagnosis of migraines the PT even tested with perfume, and light which had no change on her current pain. Subjectively that wasn’t an issue outside of the clinic anyway.
At this point it seems very straight-forward. However, regardless of the patient having been “cleared” by many medical professionals, her 3 months of progressively worse pain and hemi-facial pain is a concern for the PT.
Next is the most important and concerning data from the evaluation and is also one of the most overlooked part of an outpatient physical therapy evaluation: Vitals…
- Blood pressure: 265/138 mmHg
- HR: 98 BPM
That’s not good.
The PT questioned the patient on her BP reading. The patient had been monitoring her blood pressure herself over the past month which had been high, but not that high. The patient noted a progressive increase in blood pressure since onset of symptoms and had been monitored each time by the ED.
At this point- Red Flag.. not treating. Constant pain, very high BP. The physical therapist gave her a name of a good neurologist to go see. Finally on 10/31/2011 the patient made it into the office of the neurologist. Upon exam the neurologist found blood located behind the right retina. His next question was
Do you feel or hear a thump in your head with your symptoms?
She responded with “yes, I feel a thump in my head with my symptoms.” After that he decided to order an MRA… wait… she already had an MRA, right? The previous MRA was only of the brain. What she needed was an MRA from Subclavian to the brain. The following images are the real images of this patient.
After consult with surgeons the risk of surgical correction was too high due to the proximity of the vertebral artery dissection to the brainstem. The patient was medically managed with Neurontin, HCTZ, and Aspirin.
So.. The what’s the take away from this case in bullet format…
- CAD will often manifest as musculoskeletal pain and dysfunction, which tends to lead them to conservative treatment first by chiropractors and physical therapists.(3)
- The evidence is not clear on a cause-effect relationship of CAD secondary to manipulation, or if patients with pre-existing CAD are seeking treatment.(6-8)
- However, recent publications support cervical manipulations are a potential cause of CAD, stroke, and death.(1-7)
- A recent report(3) demonstrated 2 participants with unknown CAD died following chiropractic cervical manipulation.
- Physical therapists need to be aware there is a population, albeit small, that possess underlying CAD that put the patient at risk for a vascular accident.
- If Cervical Manipulative Therapy is a treatment of choice, patients should be screened for Ehlers-Danlos Syndrome, cardiovascular risk factors, previous traumas, previous CMT, and neurological/cranial nerve testing.(7)
- Mobilization techniques provide similar results as cervical manipulation(9), and presumably with less stress to the vasculature structures, perhaps therapists should consider cervical mobilization as the intervention of choice.(5)
Closing Note: As physical therapists it is our duty to decide how to treat our patients. No one in their right mind purposefully attempts to injure their patient or tries to lengthen treatment by means of withholding treatment. It is our job to decipher a collection of information like past experiences (clinicals, work, school), current literature, personal comfort level/confidence all while maintaining an awareness of potential bias and then putting together the best plan of care for our patient.
I hope this case study can increase the awareness of potential underlying issues that may contraindicate treatment and motivate readers to perform a good evaluation.
1.Leon-Sanchez A, Cuetter A, Ferrer G. Cervical Spine Manipulation: An Alternative Medical Procedure with Potentially Fatal Complications. Southern Medical Journal [serial online]. February 2007;100(2):201-203. Available from: Academic Search Complete, Ipswich, MA. Accessed July 12, 2015.
2.Giossi A, Ritelli M, Pezzini A, et al. Connective tissue anomalies in patients with spontaneous cervical artery dissection.Neurology [serial online]. November 25, 2014;83(22):2032-2037. Available from: CINAHL, Ipswich, MA. Accessed July 12, 2015.
3.Thomas L, Rivett D, Attia J, Levi C. Risk Factors and Clinical Presentation of Cervical Arterial Dissection: Preliminary Results of a Prospective Case-Control Study. Journal Of Orthopaedic & Sports Physical Therapy [serial online]. July 2015;45(7):503-511. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed August 9, 2015.
4.Paciaroni M, Bogousslavsky J, Cerebrovascular Complications of Neck Manipulation. Eur Neurol 2009;61:112-118. Accessed August 9, 2015
5.Gross A, Hoving J, Bronfort G, et al. A Cochrane Review of manipulation and mobilization for mechanical neck disorders. Spine (03622436) [serial online]. July 15, 2004;29(14):1541-1548. Available from: CINAHL, Ipswich, MA. Accessed September 7, 2015.
6.Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. The Lancet. Neurology [serial online]. July 2009;8(7):668-678. Available from: MEDLINE, Ipswich, MA. Accessed September 7, 2015.
7.Thomas L, Rivett D, Attia J, Parsons M, Levi C. Risk factors and clinical features of craniocervical arterial dissection. Manual Therapy [serial online]. August 2011;16(4):351-356. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed September 7, 2015.
8.Ernst E. Vascular accidents after neck manipulation: cause or coincidence?. International Journal Of Clinical Practice [serial online]. May 2010;64(6):673-677. Available from: CINAHL, Ipswich, MA. Accessed September 7, 2015.
9.Gross A, Miller J, D’Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL. Manipulation or Mobilisation for Neck Pain. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD004249. DOI: 10.1002/14651858.CD004249.pub3.