Physiotherapists’ identification and knowledge of Cervical Artery Dysfunction.

Abstract

Purpose: Neck pain is the fourth leading cause of global disability, with its prevalence exceeding 30%. Consequently, physiotherapists assess a significant number of patients with neck pain. However, some conditions, such as vertebral artery dissection, are known to masquerade as musculoskeletal neck pain and require immediate medical referral. Usual musculoskeletal management of such patients could exacerbate their condition with life threatening outcomes therefore it is vital that physiotherapists have knowledge of differing characteristics of pain presentations in order to manage each condition safely and effectively.
This study aims to investigate UK-based physiotherapists’: knowledge of Cervical Artery Dysfunction (CADF) and awareness of current guidelines.
Methods: An online survey describing two clinical vignettes based on internal carotid artery dissection (ICAD, Vignette 1) and vertebrobasilar insufficiency (VBI, Vignette 2) presentations were disseminated to a convenience sample of UK-based physiotherapists working in a musculoskeletal outpatient setting and assessing a minimum of 5 cervical spine patients a month. Survey questions explored knowledge of CADF and related guidelines. Data analysis incorporated both content and thematic approaches.
Results: Fourteen respondents completed the whole survey (17 responses for vignette 1 only). The highest educational qualification was a BSc Physiotherapy for 76% (13) and higher for 24% (4). Physiotherapy experience ranged from 1-40 yrs with 24% having completed further qualifications specific to the cervical spine. Fifty-nine percent (10) were aged between 26-35 yrs and female.
For vignette 1 (ICAD), 94% considered a diagnosis relating to CADF with 88% specifying they would perform a neurological examination in their objective assessment, and 77% and 41% proceeding to a cranial nerve and vascular assessment respectively. The majority (88%) stated onward referral in their management plan, although 71% of these suggest it would be to a General Practitioner and two (12%) to Accident and Emergency. For vignette 2 (VBI), 86% included CADF/VBI as a preliminary diagnosis however this reduced to 36% when a primary diagnosis was requested. The same proportion incorporated Coman’s 5Ds and 3Ns into their subjective assessment. Twenty-two percent specified management plans that are not recommended by current guidelines and forty-three percent were not aware of any CADF guidelines.
Conclusions: The findings suggest some awareness of CADF however not by all respondents and safety concerns were highlighted as some respondents recommended manual therapy approaches in their objective examination and management plans that would be contraindicated. Awareness of current guidelines was poor and therefore need wider promotion. Findings suggest that promotion and training related to CADF and vascular masqueraders of cervical spine pain is required. However, the sample size was small and geographically local, as such a larger study would be needed to ascertain if these findings are reflective of MSK physiotherapists nationally.
Impact: The results highlight a need for 1) further training to raise awareness of the potential for vascular conditions that masquerade as musculoskeletal head/neck pain and 2) a need to raise awareness of current guidelines.