Post on 23-Dec-2021
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Review Article
Proposing a new algorithm for premanipulative testing in physical therapy practice
Brent Harper, PT, DPT, DSc, OCS, FAAOMPT1)*, Daniel Miner, PT, DPT, NCS2), Harrison Vaughan, PT, DPT, OCS3)
1) Crean College of Health and Behavior Sciences, Chapman University: 9401 Jeronimo Road, Irvine, CA 92618, USA
2) Department of Physical Therapy, Waldron College of Health and Human Services, Radford University, USA
3) PhysioFit, USA
Abstract. In thefieldofphysical therapy, there isdebateas to theclinicalutilityofpremanipulativevascularassessments.Cervicalarterydysfunction(CAD)riskassessmentinvolvesamulti-systemapproachtodifferentiatebetweenspontaneousversusmechanicalevents.Thepurposesofthisinductiveanalysisoftheliteraturearetodis-cussthelinkbetweencervicalspinemanipulation(CSM)andCAD,toexaminetheliteratureonpremanipulativevasculartests,andtosuggestanoptimalsequenceofpremanipulativetestingbasedonthedifferentiationofaspon-taneousversusmechanicalvascularevent.Knowingwhatpremanipulativevasculartestsassessandtheassociatedclinicalapplicationfacilitatesanevidence-informeddecisionforclinicalapplicationofvascularassessmentbeforeCSM.Key words:Manipulation,Algorithm,Cervical
(This article was submitted Jun. 18, 2020, and was accepted Aug. 4, 2020)
INTRODUCTION
Traditionally,vertebrobasilarinsufficiency(VBI)hasbeenconsideredthemostconcerningriskfactorforanadverseeventduringcervicalspinemanipulation(CSM)1, 2).ThemajorityofinvestigationsofCSMadverseeventshavefocusedonVBI,specificallyinjurytothevertebralartery(VA)3–6).Anothervascularconcernreportedintheliteratureinvolvesinternalcarotidartery(ICA)dissection4, 7–11)whichwouldindicateanimmediateneedformedicalreferral12).Thepurposesofthisclinicalperspectivesmanuscriptaretodiscussthelinkbetweencervicalspinemanipulation(CSM)andcervicalarterydysfunction(CAD),toexaminepremanipulativevasculartestsintheliterature,andtosuggestanoptimalsequenceofpremanipulativetestingbasedonthedifferentiationofaspontaneousversusmechanicalvascularevent.
METHODS
Anon-comprehensiveinductiveanalysisoftheliteratureaddressinglinksbetweenCSMandCADandareviewofpre-manipulativevasculartestsinordertoproposeanewalgorithmforpremanipulativetestinginphysicaltherapy.Theanswerstothisquestionweredeterminedthroughthefollowing5-stepprocess:aliteraturesearchwasconductedinordertoidentifyinformation;copiesofarticleswereidentifiedthroughtheliteraturesearchandobtained;asynopsesofeacharticlewaswrit-teninordertocaptureanyinformationpertainingtothepurposeofthestudy,theresearchdesign,sourcesandkindsofdata,datacollectionandanalysis,results,andconclusions.Anymanualtherapysafetyoptionsusedtoscreenpatientswithneck
J. Phys. Ther. Sci. 32: 775–783, 2020
*Correspondingauthor.BrentHarper(E-mail:brharper@chapman.edu)©2020TheSocietyofPhysicalTherapyScience.PublishedbyIPECInc.
Thisisanopen-accessarticledistributedunderthetermsoftheCreativeCommonsAttributionNon-CommercialNoDeriva-tives(by-nc-nd)License.(CC-BY-NC-ND4.0:https://creativecommons.org/licenses/by-nc-nd/4.0/)
The Journal of Physical Therapy Science
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painwasnotedoneachsynopsis.MEDLINEandCINHALsearchtermsincluded“classify”,“candidates”,“manipulation”,“uppercervicalspinemanipulation”,“clinicaldecisionmaking”,“clinicalreasoning”,“evidence-basedmedicine”,“predic-tiverule”,and“clinicalpredictionrule”.Allarticlesweresearched,butonlyEnglishlanguagearticleswereobtainedbecauseEnglishabstractsofnon-Englisharticlesindicatedirrelevance.Allyearsweresearchedwith,emphasiswasplacedonarticlespublishedwithinthelastten-years.Referencearticlesfromreviewedjournalsgarneredadditionalarticles.
RESULTS
Intheirdiscussionofvascularinsufficiencies,Kerryetal.13)andKerry&Taylor14)proposedarevisionofthenomencla-ture,suggestingthetermcervical artery dysfunction (CAD)sinceitencompassespotentialcomplicationsofallarteriesinthecervico-cranialregion.Theauthorsidentifiedinherentrisksfromaglobalhemodynamicperspectiveratherthanstructuralorpathological,ashistoricallycategorized.Kerryetal.13)definedCADas:thecompletenessofthearterialanatomy(e.g.,thevertebrobasilarsystem,theinternalcarotidarteries,andtheCircleofWillis),andtherangeofpathologiesthatthemanualtherapistmayencounter (e.g., localdissection,atheroscleroticevents,vessel injury,non-ischaemic[sic]events, ischemicevents).
ThisdefinitionofCADistheInternationalFrameworkforExaminationoftheCervicalRegionstandardasadoptedbytheInternationalFederationofOrthopaedicManualPhysicalTherapists(IFOMPT)foridentificationofvascularinvolvementbeforeorthopedicmanualtherapyintervention15).IFOMPTdoesnotdiscouragemechanicalvascularpatencyassessments,andtheAustralianPhysiotherapyAssociation(APA)16)protocolincludesevaluationforvascularsymptomswhileperformingmechanicalmovementsthatstressvascularpatency.
Neurovascular structurescanbecompromisedbothexternallyand internally, resulting in symptoms.CADsymptomsfromextrinsicormechanicalfactors,inwhichanatomicalstructuresplayarole,includingosteophytes,skeletalanomalies,muscularentrapment,fibrousbands,andnerveentrapment,maycompromiseneurovascularstructures.Excessivemechani-calforces,likecervicalspinerotationandhyperextensionorCSM,arealsoextrinsiccauseswhichmayresultinmechanicalarterialdissection17).IntrinsicCADsymptomsrelatetothepathologyofthearteryitself,anarrowingofthelumen.Intrinsicfactorsincludeatherosclerosis,aneurysms,thrombosis,andemboli,anyofwhichmayresultinspontaneousarterialdissec-tion17, 18).
TheincidenceofmechanicalarterialdissectionsduetoanextrinsicfactorsuchasCSMrangesfrom1in9,000to1in10millionwithinherentunder-reporting,makingtheactualincidencechallengingtocalculateaccurately19–24).Theincidenceofspontaneousarterialdissectionduetointrinsicfactorsis1to1.5per100,000people19–24).Thus,aspontaneousarterialdissectioneventisprobablymoreprevalentthanthoseassociatedwithCSMorvertebralarterytestinglikedeKleyn’s,pre-manipulativeholdsorcervicalrotation19–24).Consequently,thereappeartobeotherfactorsinvolvedinarterialcompromisebesidesthebiomechanicalforcesassociatedwithCSMorvertebralarterytesting17, 20, 21, 25).Theseotherfactorsfocusonvari-ousmedicalco-morbidities,resultinginturbulenceinthearteries,specificallyatherosclerosis,hypertension,ordiabetesmel-litus18, 26, 27).Spontaneousarterialdissectionsappeartoberelatedtoco-morbiditiesthataffectvasculature,primarilyICAs,aswellastheVAs.TheICAsaffectedbyvascularturbulenceissuesaremorelikelytopresentwithsignsandsymptoms.Itisnosurprise,then,thatICAdissectionratesarenearlydoubletheratesofVAdissection28).Giventhevariouscorticalandsubcorticalregionsthesevesselssupply,clinicalsigns,andsymptomsassociatedwithICAdissectiondiffersignificantlyfromthoseassociatedwithVAdissection.AfulldescriptionofICAsymptomsisbeyondthispaper’sscope,butinitialsignsofICAdisruptionareoftenseenbytestingeyefunctions17,29).Thecriticalelementregardingmechanicalextrinsicandintrinsictestingisthatbiomechanicalarterialtestingwillnotassistinidentifyingthoseatriskofspontaneousarterialdissection.Infact,theactualperformanceofabiomechanicaltestonsomeoneatriskforintrinsicpathologymayenableaspontaneouseventtooccurmorereadily17).
Cliniciansmustbeabletoeffectivelyscreenforandruleoutconcernforvascularcompromisebeforeanymechanicalevaluationofthecervicalspine.Theabilitytoeffectivelyscreenforvascularcomplicationthreatsisessentialtounderstand-ingtheunderlyingriskfactorswhichmaypredisposeanindividualtocervicalarterydissection(Fig.1)17).
TheICAsprovide80–89%ofbloodflowtothebrainandgiverisetothemiddleandanteriorcerebralarteries.TheVAsjointoformthebasilararteryandcontribute11–20%ofcerebralbloodflowtotheposteriorcirculationofthebrain30, 31).ThecourseoftheVAvariesandismorelikelytobeanomalousinindividualswithcongenitaldeformitiesofthecranio-cervical junctionorwithahistoryof traumainvolvingatlantoaxialsubluxation32, 33).Upto20%of thepopulationhasanormal anatomical variation of some type.Theoretically, anomalies of theVA, or any artery,may alter hemodynamicsby increased turbulence,whichmaypredispose the individual toaneurysms, thus increasing the risk forcerebrovascularaccident(CVA)17, 27).Despiteanatomicalvariations,theirimpactontheriskofVAdissectionisunknown34, 35).
TheVApassesthroughfourdistinctanatomicalzones.Inzone3,theVApassesthroughthetransverseforamenofC1andmakesasharpturnhorizontallyacrossitbeforepiercingthroughtheduramater.Fiftypercentofcervicalrotationoccurswithinzone3attheatlantoaxial(AA)jointbetweenC1andC2,causingthemostsignificantimpactontheVAasitmaybe“tethered”atvariouspoints11, 34, 35).Therefore,thetortuouscourseoftheVAinzone3correlateswiththelocationmostfrequentlyatriskfromCSM36–38).
TheanatomicalcourseoftheVAanditspotentialvulnerabilityatfixationpointsmightaffectbloodflowduringcervical
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activerangeofmotion,premanipulativemechanicaltesting,orCSM.TheVAisstretchedmoresignificantlyduringrotation,whereas the ICA is stretchedmore during extension39, 40).Thesefindings have been the foundational premise for usingpremanipulativetestingtoassessforcompromisedcirculationinthecervico-cranialarteries41).
Premanipulativemechanical(extrinsic)vascularassessmentsaretheestablishedstandardofcare;deKleyn’stestisoneof themostcommon42).Symptomprovocationwithpositional testing indicatesapositivedeKleyn’s testconsistentwithCADandindicatesCSMcontraindication.Researchers43)measuredcervicalbloodflowinneutralanddeKleyn’spositionusingdopplerultrasoundtomeasurebloodflowvelocityon20individualswithapositivedeKleyn’stest.SignificantclinicalinconsistencieswerefoundbetweendeKleyn’stestanddopplerfindings.Theresearchersconcludedapositivepremanipula-tivetest,suchasdeKleyn’s,doesnotindicateanabsolutecontraindicationtoCSM,butwouldindicateaneedforreferralfordopplerultrasoundexaminationofthearterialflow.Finally,theauthorsstatedthatifthefollowupdopplerultrasoundisnormal,thenCSMisnotcontraindication,evenwithpositivepremanipulativetest43).
ThemostsignificantriskofupperCSMiscervicalarterialdissectionleadingtostrokeordeath44).Zainaetal.45)examinedtheeffectofcervicalrotationonC1–2contralateralVAbloodflowpeakvelocityandonC5–6ipsilateralVAvolumeflow
Fig. 1. Algorithm:clinicalreasoningsequencefordeterminingvascularrisk17).AROM:ActiveRangeofMotion;CSM:CervicalSpineManipulation.
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rate,andwhethertherewasacumulativebloodflow.Twentyparticipantswereexaminedwithultrasounddopplerinaseatedpositionwithheadneutral,at45degrees,andinendrangecervicalrotation.Noneof theparticipantsweresymptomaticduringtesting,andnosignificantdifferenceswerefoundat45degreesorend-rangerotationsinthebloodflowparametersofpeakvelocityatC1–2andvolumeflowrateatC5–6.Repetitionoftherotationalpositioningdidnothaveacumulativeeffect,demonstratingthatcumulativepremanipulativetestingdidnotharmtheVAsinthoseparticipants45).Furthermore,Erhardtetal.46)assessedhaemodynamicsonhealthyadultsatC1–2andfoundnodeletreiouseffectstoVAbloodflowwhencomparinghigh-velocitylowamplitude(HLVT)thrusttechniquetopremanipulativeholds.
SpecificbloodflowturbulenceassessmentssuchasdopplerultrasonographyhavedemonstratedthatspontaneouschangesinVAandICAbloodflow16, 47, 48)arenotalwaysdirectlyrelatedtoCSMmechanicalforces,butmaybeintrinsicallybased.Atpresent,therearenodefinitivefindingsrelatingbloodflowchangestoCSMandliteratureismixed;severalstudiesshowareductionincontralateralbloodflowduringcervicalrotation49–53),whileothersshownobloodflowchanges54–57).Onestudy58)usedMRItoassessbloodflowofhealthyindividualsduringvariousnon-manipulativeproceduressuchasend-rangecervicalrotation,uppercervicalrotation,orfirmaxialdistractionandfoundnoalterationsinbloodflowandconcludeditunlikelythatend-rangeneckrotationanddistractionpositionsarehazardoustothecerebralcirculation.Furthermore,theauthorssuggestedspecificsegmentallylocalizedtechniquesposednohigherrisktocerebralcirculationthanthemechanicalpositions tested58).Other research59) on healthy, asymptomatic patientswith decreased bloodflow inVAs and ICAs, asconfirmedbymagneticresonanceangiography,hadnegativepositionaltestsforCADduringmechanicalendrangerotationtesting.Theresultsofthesestudiescallintoquestiontheutilityofmechanicalvascularassessmentprocedures.Thomasetal.59)hypothesizedthatcompromisedbloodflowinonearteryisnaturallycompensatedforbycollateralflowthroughthearterialCircleofWillis,whichhelpstomitigateanysymptomswhichmayhaveresultedfromdecreasedcirculation.Thisevidencemaysuggestthatindividualswhoexperienceend-rangecervicalrotationsymptomsmaynothaveCAD,butmayhavedysfunctionmoreproximally(intrinsic)intheintracranialcirculationoftheCircleofWillis59).
Furthermore,Symons&Westaway27)arguethatbiomechanicalvertebralarterialtests,likedeKleyn’s,andmanualinter-ventions,likeCSM,maynotdisruptvertebralarterybloodflowfortworeasons.First,mostpeoplehavefourmajorarteriesthatsupply theCircleofWillis,allowingcollateralreflexivevascularcompensationforanybrainperfusiondeficits.TheauthorsprovideevidencethatcompensatorybloodflowoccurswithoutresultinginanincidentofVBI,evenwhen100%ofthevertebralarteryisoccluded.Second,theauthorsreportthatCSMistoofast,occurringat200milliseconds,ifperformedcorrectly inmid-rangeandnotatend-range tension,whichdoesnotstress theneurovascularstructures likeaprolongedstretch.Therefore,CSMproceduresaretoofasttocausearterialdamageifperformedintheproperrangeofmotion.TheauthorsconcludethatifCSMinducesVBIsignsandsymptoms,itdoessoonlyinthepresenceofotherfactorslikewhenaspontaneouseventisalreadyinprogress27).
Eventhoughpremanipulativemechanicalvascularassessmentsaretaughtinentry-levelphysicaltherapyprograms,theycontinuetobechallengedandquestionedasobjectiveclinicaltests.Duetoreducedsensitivity11, 13, 14, 48, 60),thesetestsareas-sociatedwithahighrateoffalsenegatives6)andhavepoorabilitytodiscriminatebetweenindividualswithorwithoutarterialpathology.Evidence-informedpracticeindicatesthatclinicianscannotrelysolelyonsymptomprovocationwithmechanicalvascularassessmentstodefinitivelyruleoutcervicalarterydysfunctionduetothepoordiagnosticaccuracyofthesetests3, 60).
Insummary,oneofthefirstclinicaltestsforcervicalarterialdysfunctionwasdescribedbydeKlyneover50-yearsagoandcontinuestobecommonlyused4)eventhoughconcernsrelatedtodiagnosticaccuracyhavepreventeditsintegrationintoclinicalpredictionrules.Bloodflow45, 54, 57, 58), VA61, 62),andICA61)strainstudiesfoundacompletelackofconstructvalidityforpremanipulativevascularscreeningtests.Theliteraturefailstosupporttheabilityofpremanipulativeteststoidentify,throughpositiveornegativetestfindings,individualsatriskforapost-CSMvascularevent3,5,11,13,39,63),toprovideanyusefuladditionaldiagnosticinformation64);andhasidentifiedahighfrequencyoffalsenegativeVAtests65).Manyauthorsadviseagainstusingmechanicalvascularteststoassessvascularpatency,primarilywhenathoroughhistoryidentifiessignsandsymptomsconsistentwithCAD13, 60, 64).Finally,theevidencesuggeststhatactiverangeofmotionputsmorestrainontheICAthanCSM61).
Limitationsincludedlackofaccesstonon-publishedprofessionalconferencesandthepossibilitythatsomenon-Englishprofessionalwritingsintheformofbooksandjournalarticlesmighthavebeenrelevanttothesubjectstudiedinthispaper.
DISCUSSION
TheAustralianPhysiotherapyAssociation(APA)VAprotocol16)recommendsconductingactiverangeofmotion(AROM)andpositionalvascularpatencytestwhensymptomsofVBI/CADareunclearonpatientswithavaguesubjectivehistoryforpotentialVBI/CADsymptoms.IntheUnitedStates,vascularscreeningremainscommonpracticepriortoCSM.Despitethecurrentresearch,IFOMPT15)doesnotspecificallydiscouragemechanicalvascularpatencyassessments.ICAvascularcompromise is associatedwith spontaneousarterialdissection; thus, assessments forovert symptomsor thepresenceofvaguesignsandsymptomsassociatedwithICAischemiaisvital,inconjunctionwithathoroughhistoryofco-morbiditiesandevents(Tables1and 3)beforeanymechanicalstressisplacedintheregion17),suchasvascularscreeningormechanicalstressors(AROM),
DespitethelackofsupportformechanicalvascularassessmentsforCAD,thereremainssomeclinicalvalueinprema-nipulativescreeningtests.Thekeytounderstandingtheirclinicalvalueisinacknowledgingthatmechanicaltestscannot
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identifyriskforspontaneousCADand,aspreviouslystated,maycauseavascularevent. If therearenoriskfactors forvasculardiseaseandnegativenon-vascularpatencyscreeningtests(likeheartrate,bloodpressure,bruits)forsystem-widespontaneousvascularcompromise,thenthereisminimalriskofprovokingavasculareventthroughtheuseofmechanicalvascularscreens.Ontheotherhand,ifpositiveriskfactorsareidentifiedforaspontaneouseventoriftheclinicianisunsure,theclinicianwouldbeunwisetoattemptprovocationthroughmechanicaltesting.Therefore,mechanicalpremanipulativetestsarenotemployedwhentheclinicianhasanysuspicionthataspontaneousvasculareventisimminentorhighlyprob-able13, 17, 66),butmaybeusefultoassessanindividual’sphysicalandemotionaltoleranceintherangeinwhichtheCSMwilloccur17).
Itistheopinionoftheauthorsthatthecurrentevidencedoesnotsupporttheutilityofroutinelyperformingpremanipula-tivescreens,suchasdeKlyne’s, to identifyCAD.Presently,basedon thecurrentmedico-legalconstraintsgoverning theprofession,premanipulativescreensshouldbedone,whenappropriate,formedico-legalpurposesduetothesocietalpercep-tionoftherisksforadverseevents,eventhoughtheevidencedoesnotsupportthetests,untilwhichtimetheexpectationsofexcludingmechanicalpremanipulativetestingbecomes“standard”practice17).
Thisclinicalusefulnessofthisstudyisinitsemphasisontheorderofoperationsforsafelyscreeningforspontaneousarterial dissectionprior toAROM, and in the recommendation that vascular screening tests arenot useful for assessingvascularpatency,butmightbeusefulafterclearanceforspontaneousdissection(Table1)toassessanindividual’smechani-calandemotionaltolerancewithintherangeCSMwilloccur.ThisalgorithmisintendedtoaddtoAPA16)andIFOMPT15) premanipulativeCADguidelines (Fig.1)and isbasedon intrinsicversusextrinsicdisorders.Screening for spontaneoushemodynamicCADinvolvesacombinationofassessingforco-morbidities,investigatingpatienthistoricalevents,evalu-atingsubjectivecomplaints,andprovidingappropriatephysicalexaminationprocedures11, 13, 14, 17, 67).Oncespontaneousvascular sequelaeevents (intrinsicdisorders) (Table1)havebeenscreenedasnegative forvascularco-morbidities, thenpremanipulativescreeningformechanicalarterialcompromise(extrinsicdisorders)(Table2)canbeperformed,nottoassessarterialpatencyintermsofVBI/CAD,buttoevaluateforpotentialintolerancetomechanicalforceswhichmayoccurduringCSM17)(Table3).
Table 1.Optimalsequenceofpremanipulativeassessment(intrinsic)11, 13, 14, 17, 67)
Spontaneousarterialdissection(intrinsicdisorder)
History–Subjectiveexam/SE
1.Symptoms:5Ds(Diplopia,Dizziness,DropAttacks,Dysarthria,&Dysphagia),3Ns(Nausea,Nystagmus,&Numbness),Headache,Ataxia
2.Co-Morbidities(Anythingthatincreasesturbulence):Atherosclerosis,Hypertension(HTN),DiabetesMellitus(DM),historyofmigraine,geneticdefects(e.g.,increasedlevelsofaminoacidhomocysteinecreatingfragilityofthearterialwalls)
3.HistoricalEventsa)Asuddenonsetofseveresharpposteriorcervicalandoccipitalpain.b)Ahistoryofsmoking(especiallylong-standinghistory).c)Episodicdizzinessorvertigolastinggreaterthanoneminuteinisolationorwithpre-manipulativescreeningtest.d)Previoushistoryofischemicattacks.e)Ahistoryoftrauma(especiallyifitincludedwhiplashthatinvolvedaflexion-distrac-tion-and-rotationforce).
Tests&Measures–Objectiveexam (Physicalexam/PE)
HeartRate(HR),BloodPressure(BP),Auscultationforbruits,cranialnerveexamination,generaleyeexamination,labbloodtests(aminoacidhomocysteinelevels).
Table 2.Optimalsequenceofpremanipulativeassessment(extrinsic)11, 13, 14, 17, 67)
Mechanicalarterialcompromise(extrinsicdisorder)History–Subjectiveexam/SE 1.HistoricalEvents
a)Asuddenonsetofseveresharpposteriorcervicalandoccipitalpain.b)Ahistoryofsmoking(especiallylong-standinghistory).c)Episodicdizzinessorvertigolastinggreaterthanoneminuteinisolationorwithpre-manipulativescreeningtest.d)Previoushistoryofischemicattacks.e)Ahistoryoftrauma(especiallyifitincludedwhiplashthatinvolvedaflexion-distrac-tion-and-rotationforce).
Tests&Measures–Objectiveexam(Physicalexam/PE)
deKleyn’stest,FullPhysiologicalCervicalRotationtest,Pre-ManipulativeHold(PMH)test,HandheldDopplerVelocimeter.
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FundingNone.
Table 3.Clinicalreasoningsequencefordeterminingvascularrisk(Fig.1)11, 13–15, 17, 43, 67)
History– Subjectiveexam(SE)
Review of Systems (General Health):Intakequestionnairescreening.Co-Morbidities: Higher Suspicion with Increased System Involvement and Subjective ReportsAtherosclerosis;associatedfactorsinclude:Hypertension,Hypercholesterolemia,Hyperlipidemia,Hyperhomocys-teinemia,Heartdisease,Diabetesmellitus,Lupuserythematosus,alcoholism,Geneticclottingdisorders,infections,smoking,Directvesseltrauma,Iatrogeniccauses(surgery,medicalinterventions).Genetic / Lifestyle Factors:Femalegender,advancingage,obesity,sedentarylifestyleandprolongedbedrest,cigarettesmoking.Subjective complaints of:Dizziness(vertigo,giddiness,lightheadedness),Dropattacks(lossofconsciousness),Diplopia,Dysarthria,Dysphagia,Nystagmus,Nausea,Numbness,Headache,andAtaxia.History of:Headacheorneckpain,especiallyifsuddenandsevere,vomiting,facialsensationalteration,blurredvision,tinnitus,historyofpasttrauma,(particularlyahigh-velocityflexion-distractionwithrotationalforces,likethoseoccurringduringawhiplashincident),nystagmus,alteredbloodpressure,previoustransientischaemicat-tacks,Horner’ssyndrome.Historical Events:Asuddenonsetofseveresharpposteriorcervicalandoccipitalpain.Ahistoryofsmoking(especiallylongstandinghistory).Episodicdizzinessorvertigolastinggreaterthanoneminuteinisolationorwithpre-manipulativescreeningtest.Previoushistoryofischemicattacks.Ahistoryoftrauma(especiallyifitincludedwhiplashthatinvolvedaflexion-distraction-and-rotationforce).
Tests& Measures–Objectiveexam(OE)
Structural InspectionSystemsReview(SpecificSystems):VitalSignse.g.,HeartRate(HR),BloodPressure(BP),RespiratoryRate(RR),Oxygensaturation,etc.PalpationAuscultationofbruits.Pulsepalpation/examinationandgeneralvascularassessment(e.g.,nailbedrefill,etc.).Special TestsCranialnerveexamination(maybelistedunderNeurologicalTestsorSpecialTest).CNII(visionandeyeexam;acuity(Snellencharts),colorvision(Ishiharaplates),visualfields,visualreflexes(reac-tivitytolight),fundoscopy,CNIII,IV,VI(ExtraocularMuscles)GeneralEyeexaminationmayinclude:1.Eyeposition&alignment/Upper&Lowereyelidsinrelationtoeyeball.2.PupilPERRLA
P=PupilsizewithchartinMM(3–4.5normal) E=Equal/Symmetricalsizes(subtledifferencesisnormal) R=Shape(normalisround) R=Reactivetolight(directresponse=pupilnarrowswithdirectlighttoeye) (consensualresponse=pupilnarrowslightoppositeeye) L=Lacrimal(inspectregionslacrimalgland/sacforswelling) (lookforexcessivetearingordryness) A=Accommodation(pupilconstrictsandexpandswhenfocusingonshortandnearobjects)
3.VisualAcuity(SnellenChart)4.ExtraocularMuscles(checkingsmoothpursuit/gazein“H”pattern;pauseduringupward&lateralgazetodetectnystagmus)(Normal=afewbeatsofnystagmusonextremelateralgazeisWNL)
DirectMechanicalTestingOptionsInclude/FunctionalPositionTests:1.Fullphysiologicalcervicalrotation.2.deKleyn’sTest(subjectpositionedattheendofthebedat3rdthoracicsegmentwithcervicalsegmentshangingoffthetabletoallowforfullsupportedextension-rotation).
3.Pre-manipulativehold/PMH(positionedincranio-vertebralsideflexioncombinedwithcontralateralrotationdowntoandincludingatlanto-axialjointwithdigitalpressureonC1–C2justshortofmanipulativethrustandheldforaminimumof10seconds).
4.HandheldDopplervelocimetry. Ifmechanicalpremanipulativetestsarepositive,referpatientforDopplerultrasonography.
LAB ValuesElevatedlevelsofaminoacidhomocysteine.NormalLevels(plasma):Males4–12micromoles/L,Females4–10micromoles/L.Levelmaybeconsideredelevatedif>9micromoles/L.
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Conflict of interest
Theauthorshavenoconflictofintereststodisclose.
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