Cervical Arterial Dysfunction and Physical Therapy
Orthopedic Manual Physical Therapy for Neck Pain and Headache ...But Not Always!
Presentations including neck pain and headaches are commonly treated with manual therapy and therapeutic exercise. Orthopedic manual physical therapy includes many techniques, including soft tissue mobilization, joint mobilization, and thrust manipulation. (Here is a brief overview of orthopedic manual physical therapy, and here is a comprehensive summary of the scientific evidence behind how orthopedic manual physical therapy works.) Therapeutic exercises for the cervical spine may include active range of motion, stretching, strengthening, coordination exercises, and endurance exercises. Research has shown that manual therapy and exercise are effective for patients with neck pain and/or headaches (1,2,3).
However, not all patients presenting with neck pain or headaches are appropriate for orthopedic manual physical therapy and exercise.
There are rare cases in which neck pain and headache may be the first signs of very serious pathology, including cervical arterial dysfunction (CAD) or upper cervical instability (UCI) (4). (For information on other serious conditions commonly presenting with musculoskeletal symptoms, here is a comprehensive overview of medical screening for red flags by a physical therapist.) Treating these patients with orthopedic manual physical therapy and exercises is contraindicated as it may put the patient at risk of further injury.
So, how can patients with cervical artery dysfunction be identified?
How to Identify Cervical Artery Dysfunction
The vertebral and the internal carotid arteries both supply blood to the brain. The vertebral artery travels posteriorly and the internal carotid travels anteriorly in the neck region. Head movements, mainly cervical rotation and extension, can decrease blood flow in these arteries (4). Dysfunction in either of these vessels can present as head and/or neck pain. Non-ischemic signs are physical signs of arterial changes that can be felt despite vascular circulation. Non-ischemic signs can be precursors to more serious ischemic signs, where blood perfusion through the vessel is impaired or even blocked, resulting in different symptoms.
Common non-ischemic signs of internal carotid or vertebral artery dysfunction include posterior neck pain, occipital headache, C2-C6 nerve root impairment, pulsatile tinnitus, Horner’s syndrome, and CN palsies (IX-XII) (4,5). Other non-ischemic signs that are not as common are facial pain, ptosis, carotid bruit, scalp tenderness, and orbital pain (5). Common ischemic signs include hindbrain stroke (Wallenberg’s syndrome); dysphagia, diplopia, dysarthria, drop attacks, dizziness, nystagmus, nausea, facial numbness, (referred to as the “5 Ds and 3 Ns”); ataxia, transient ischemic attack, stroke, and amaurosis fugat (episodic vision loss) (5). Therefore, it is critical for the physical therapist to be aware of potential cervical arterial dysfunction and properly screen patients with headache or neck pain to ensure they are appropriate for physical therapy.
Proper screening for cervical arterial dysfunction includes a thorough history and physical exam. Patients should be asked about their blood pressure, cardiac history, history of smoking, diabetes, high cholesterol, the “5 Ds and 3 Ns” (listed in the common ischemic signs in the paragraph above), balance deficits, and changes in vision or taste. They physical exam for patients with headache and/or neck pain should include blood pressure, heart rate, a cranial nerve exam, and a neurological exam, especially for patients that have had recent trauma, or a headache ‘like no other’ (5). Positional tests, such as the vertebral artery test, have poor diagnostic utility (a positive test for positional tests may not, in fact, be a true positive and a negative test may not be a true negative), and therefore should not be relied on for clinical decision-making (5,6). A system-based approach to cervical arterial screening can help clinicians properly assess risk and whether or not patients are appropriate for manual therapy and/or exercises directed at the cervical spine.
Approaching Neck Pain and Headache Conservatively
A conservative approach to manual therapy and exercise for a new presentation of neck pain and headache might be initiated with treatment to the thoracic spine first (based on the principle of regional interdependency) along with a graded progression of treatment to the cervical spine – utilizing lower forces and neutral to mid-range procedures first, gradually progressing to higher grades of mobilization or sustained stretching on subsequent visits as appropriate. All patients must continue to be reassessed throughout their care, and patients with neck pain and headache are certainly no exception.
Dr. Damon Bescia is a fellowship-trained Doctor of Physical Therapy, board certified in orthopedics and sports physical therapy, who specializes in Orthopedic Manual Physical Therapy and serves Naperville and its surrounding communities by way of his Concierge Practice, providing private one-to-one orthopedic manual physical therapy for his clients. For more information, please visit https://www.napervillemanualphysicaltherapy.com.
1. Puentedura EJ, Landers MR, Cleland JA, Mintken PE, Huijbregts P, Fernandez-de-las-Penas C. Thoracic spine thrust manipulation versus cervical spine thrust manipulation in patients with acute neck pain: a randomized clinical trial. J Orthop Sports Phys Ther 2011;41:208–20.
2. Cleland JA, Mintken PE, Carpenter K, et al. Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a general cervical range of motion exercise: multi-center randomized clinical trial. Phys Ther. 2010; 90: 1239– 1250.
3. Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache. SPINE. 2002; 27(17): 1835–1843.