Physical therapists are highly trained in rehabilitation techniques for neck pain. But not all neck pain is caused by a musculoskeletal origin. A recent article published in JOSPT "International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention: International IFOMPT Cervical Framework" discusses the importance of determining risk factors that should be considered prior to initiating cervial spine treatment. Read the full article here to learn about the purpose of developing a framework, how it can help clinicians, features of potential cervical vascular events and related testing, as well as case studies.
Are you currently screening for cervical vascular pathologies? This article indicates that "within the cervical spine, events and presentations of vascular pathologies of the neck are rare but are an important consideration as part of patient examination. Vascular pathologies may be recognizable if the appropriate questions are asked during the patient history–taking process". Follow these guidelines to start screening for vascular pathologies in the cervical spine.
Shared Decision Making
Adopt the SHARE approach to allow for informed, consuensual decision making.
Seek patient participation
Help your patient explore and compare treatment options
Assess your patient's values and preferences
Reach a decision with your patient
Evaluate your patient's decison
Understanding Pathology
Possibilities on the vascular spectrum that should be considered as potential vascular pathologies in the cervical region prior to initating cervical musculoskeletal interventions.
Atherosclerosis
Thrombosis
Hypoplasia
Stenosis
Aneurysm
Dissection
Giant cell arteritis
Understanding Risk
Epidemiological Risk: The population historical data indicates that vascular incidents related to neck pain have an extremely low prevalance and events are rare.
Individual Risk: A patient's individual factors obtained from a medical history and overal risk profile can raise or lower the relative risk for a vascular events.
Physical Exam Planning
In patients with individual risk factors and positive clinical features it is recommended to:
Take blood pressure
Perform a neurologic exam
Perform a carotid artery exam
Take caution, or avoid completely the following:
Rely on positional testing
Conducting a full physical exam without consideration of vascular
The following clinical features should raise your index of suspicion for a vascular origin of symptoms:
Acute hypertension and/or tachycardia
Abnormal or asymmetric cranial nerve exam
New balance or coordination deficits
Significant past medical history
Acute pain or headache that is "unlike any other"
Abnormal or asymmetric carotid pulse or rhythm
Referral & Treatment Planning
With a high index of suspision for vascular risk refer to the appropriate professional and setting based on level of urgency or emergency:
Mildly hypertensive (only clinical feature): Likely low risk and should be referred via a routine call to their PCP and the patient should be provided with education.
Abnormal or asymmetric carotid pulse or rhythm: ED referral
BP of 200/115 (that is not usual): ED referral
Sudden, severe neck or head pain "Unlike any other": ED referral
With a low index of suspision for vascular risk, initiate treatment based on musculoskeletal best practices, considering:
Pain management educaiton
Lifestyle education
Mobilization, manipulation or other manual treatment
Specific and general exercise
Learn more about cervical vascular screening along with heart and lung auscultation, vascular doppler and ankle brachial index, cranial nerve exam, upper motor neuron exam, carotid artery exam and more in Redefine Health Education's Foundations for Primary Care - A Hands-On Workshop.
Learn more about Redefine Health Education here.
