Objective:
Upon completion of this session, attendees will have contemporary knowledge and skills regarding identifying and management of a possible vasculogenic cause of the complaints, in patients with headache or neck pain.

Description
Neck pain is a highly prevalent condition that can lead to consider-
able pain, disability and economic costs. Cervical spine manipulation and mobilization are frequently used in the management of neck pain and headache. Although rare, serious adverse events following cervical spine manipulation and mobilization have been described in literature (Kranenburg et al., 2017). The current opinion with regard to vascular events is that patients presenting with neck pain and headache who develop a serious adverse vascular event (in particular, arterial dissection) during or after treatment may have an underlying pathology or flow limitation that was not recognized and was subsequently aggravated by treatment (Rushton et al., 2022; Rushton et al., 2020; Hutting et al., 2022). Additionally, some interventions or practices may impose greater stress on the cervical arteries and should be recognized.

Although events and presentations of vascular pathologies of the neck are rare, they are an important consideration as part of an Orthopedic Manual Physical Therapy (OMPT) assessment (Rushton et al., 2020). Vascular pathologies may be recognizable if the appropriate questions are asked during the patient history, if the interpretation of elicited data enables the recognition of this potential, and if the physical examination can be adapted to explore any potential vasculogenic hypothesis further (Rushton et al., 2021).

To assess and recognize a potential vasculogenic contribution, up-to-date knowledge and skills are important (Hutting et al., 2022). However, evidence suggests that physical therapists, including OMPTs, do not always have sufficient knowledge to conduct an evidence-based clinical reasoning process (including patient history and physical examination) regarding the identification of vascular pathologies or blood flow limitations. For example, although the current explanation is that people who develop a serious adverse vascular event after OMPT have an underlying pathology or flow limitation, about 47% of the physical therapists (n=776) believe that there is an increased risk of arterial dissection after cervical spine manipulation (Thomas et al., 2011; Thomas et al., 2015; Mourad et al., in preparation). Therapists mainly focus on manipulation as a cause of serious adverse events (Mourad et al., in preparation; Mourad et al., 2021), while the evidence to support this is lacking.

Knowledge about risk factors is also lacking. For example, over 50% of the physical therapists believe that cardiovascular risk factors are associated with a high risk of carotid or vertebral artery dissection, while literature suggests that this is not true (Mourad et al., in preparation). In addition, therapists often lack the knowledge and skills to conduct a contemporary pre-treatment examination. Anecdotal evidence (based on polling among about 200 physical therapists) suggest that OMPTs mainly rely on the results of positional testing (VBI tests) (about 70% of the therapists are still using these tests to the determine the risks associated with treatment), while the use of these tests is generally not recommended for this purpose (Hutting et al., 2020; Rushton et al., 2022). A recent survey found that positional testing is currently used in 30% of the patients with neck pain of headache (Mourad et al., in preparation). However, although positional testing and craniovertebral ligament testing are excluded from the IFOMPT Cervical Framework (Rushton et al., 2020; Rushton et al., 2022), most educational programs will keep these tests in their curriculum (Hutting et al., 2022). Moreover, although not recommended, a considerable number of educational programs still teach end range manipulations in the middle and lower cervical spine (33.3%) and upper cervical spine (25.5%) (Hutting et al., 2022).

Conclusion
As contemporary musculoskeletal physical therapy clinicians are evolving into more rounded, expert health care professionals in more diverse settings, they should be aware of a potential vasculogenic contribution to the patient’s complaints, and assess and refer the patient accordingly. To assess a potential vasculogenic contribution, up-to-date knowledge and skills are important. However, we can conclude that there is sufficient evidence indicating that physical therapists, including OMPTs, do not always have sufficient knowledge and skills to conduct an evidence-based clinical reasoning process regarding the identification of vascular pathologies or blood flow limitations. Therefore, this workshop will focus on contemporary practical knowledge and skills regarding clinical reasoning (including the subjective and objective examination) aimed at identifying a possible vasculogenic cause of the complaints, in patients with headache or neck pain.