Physical Examination 204: Cerebral and Vascular Risks

Cerebral and vascular risk screening for the chiropractor: the vascular anatomy of the brain and neck (Circle of Willis, carotid and vertebral arteries, aorta); stroke identification — general symptoms, how men and women present differently, left- versus right-brain strokes, and the history, examination, laboratory and imaging workup; the conditions that raise stroke and cervical artery dissection risk — cardiovascular disease, Marfan syndrome, Ehlers-Danlos syndrome, scleroderma, lupus, bicuspid aortic valve, the hypermobility syndromes, medications, trauma and other risk factors; stroke types (ischemic, hemorrhagic, brain stem, cerebellar, lacunar, cryptogenic, silent, TIA) and their treatment; aortic aneurysms; stroke prevention; the evidence on neck manipulation and adverse cardiovascular events, with contraindications and precautions; and correlation versus causation.

John H. Riggs III, MBA, DC, DIANM — Diplomate of the International Academy of Neuromusculoskeletal Medicine, former Chair of the Texas Board of Chiropractic Examiners Enforcement Committee and Texas Chiropractic College postgraduate faculty — teaches the 2-hour course. It is written for every Doctor of Chiropractic who adjusts the cervical spine and wants a defensible pre-manipulation screen: the history that surfaces risk, the examination findings that matter, the patients who are contraindicated or need precautions, and an evidence-literate answer when a patient asks about strokes.

The course gives the honest answer the literature supports. Several meta-analyses and case-control studies report a small but statistically significant association between cervical manipulation and stroke or cervical artery dissection (an odds ratio of about 1.74 in the 2018 analyses), while a 2012 systematic review found conclusive evidence for a strong association lacking and the quality of much of the evidence is poor. What is not settled is whether the events are caused by the manipulation or occur in patients whose dissection was already under way when they sought care for neck pain and headache — the correlation-versus-causation problem the course closes on. The practical response is the screen: a thorough history for cardiovascular disease, connective tissue disorders, medications and trauma, an examination that includes auscultation for bruits and instability, avoiding end-range extension and rotation, low-force alternatives where risk is present, and a differential diagnosis before any neck is adjusted.

Physical Examination 204 is online and on-demand: you start immediately after checkout and work at your own pace. When you pass the post-course assessment your completion is recorded electronically and your certificate is issued right away. CCEDseminars is PACE Provider #34015544 and the course is co-sponsored by Texas Chiropractic College; completions are reported to CE Broker for the states served. Approved states are listed at the bottom of this page, and confirming your own board's requirements remains your responsibility.

Dr. O'Hara's Physical Examination 202: Neck and Upper Extremities is the natural companion — 204 is the vascular screen that comes before the cervical examination 202 teaches — and Dr. Hall's Physical Examination 201: Current Concepts in Pupillometry covers the neurological side of the same encounter. Any three Physical Examination courses reach 6 CE hours, where the automatic 10% multi-course discount starts ($108 instead of $120). New Physical Examination titles are released as faculty complete them; the current list with pricing lives on the category page.