#35 - Reframing Acute Neurological Deficits with Dr. Harrison Vawter, Part 1

FAKTR, spelled F-A-K-T-R, stands for Functional and Kinetic Treatment with Rehabilitation. Over the past decade, this unique approach to treating pain and dysfunction has been utilized by healthcare providers on 6 continents. Serving as a framework that guides clinical decision-making in patient visits around the globe on a daily basis. With this podcast, our goal is simple: to bring the best and brightest in clinical education to the forefront and empower practitioners with cutting-edge, evidence-based content that improves patient outcomes and inspires healthcare providers to continually evolve their approach to treatment. In each episode, we will feature a training or interview with some of the top minds in healthcare in a short format that is easy to consume. to digest with actionable information that you can implement into practice right away. Let's get started. Hi guys, welcome to a new episode of The Factor Podcast. I'm your host, Jessica Riddle. If this is your first time tuning in, welcome and thanks for listening. Today we begin a new 2-part training with Dr. Harrison Vauder titled Reframing Acute Neurological Deficits. We've all seen the headline stories about patients who have allegedly suffered stroke after receiving spinal manipulations. The media attempts to place blame on the chiropractor, but what does the research really say? In today's episode, we do a deep dive into what the literature has to say about chiropractic and acute neurological deficits so that you know how to spot the signs and red flag symptoms when they present in your office. Dr. Harrison Vauter is a graduate of Cleveland University undergraduate and graduate programs. He now serves as an adjunct faculty at Cleveland, teaching a course specifically dedicated to assessment and management of emergencies in the private practice setting. Over the last 10 years, Dr. Vauter has been paramedic in the Kansas City area, working in both the field and in the Emergency Medical Sciences program at Johnson County Community College. He teaches EMR, EMT, cardiology, and paramedic content both in didactic settings And also in clinical settings, working with students in a variety of hospital roles throughout the city. Dr. Vauder is also in private practice where he owns and operates Industrial Athletics, which is an industrial athletic development and monitoring strategy specifically for police, fire, EMS, and healthcare workers. Now guys, this is definitely a topic I encourage you not to sleep on today. During this 2-part training and this podcast series with Dr. Vauder, You may learn something that helps to save a life. Now, let's cue the intro music and get started.

My name's Harrison Vauter. I am a graduate of Cleveland Chiropractic College in Kansas City. I have kind of a unique story. I went to chiropractic school after I worked as a paramedic in a high call volume suburban EMS system. So I've been a paramedic for 10 years. I teach the EMS paramedic and the EMT programs at our local community college. And I did that all through school and I taught it all. I'm fortunate enough to teach at all of the levels. So I got to teach like in the classroom setting, and then I got to teach in that like skills and simulation setting. And then I also get to go out into the hospitals and work with students in the hospital. So what that looks like is I interact with students in the emergency room or in the labor and delivery room or in the operating room when we're learning how to manage airways and all that stuff. So I have like, the stars have aligned in my favor in a lot of ways, and especially this way where I've had a wide variety of experiences to set me up for this kind of niche topic. So that's my little backstory. I'm in private practice in Kansas City. I have kind of a sports performance flavored practice that really targets public safety professionals. And that's that side of my life. I teach at Cleveland Chiropractic also. And, and this is a spinoff of some of the content that I get to teach to those students over at Cleveland. So the reason I have this labeled acute neurologic deficits is because we don't know if it's a stroke. Chiropractors have this idea that like, oh, this is a stroke or that's a stroke, or we like to throw the word stroke around. And that's it. And all I can tell that patient definitively is you have a neurologic deficit that's acute. That's all I know. So I have some of the language a little bit different than you might have heard in other continuing education stuff because of my background in EMS. In EMS, it's similar. We don't have a ton of diagnostic tools, and the diagnostic tools that we do have might have good specificity, but they have poor sensitivity. So they don't do a good job of ruling things out, but they do a good job of ruling things in, like a 12-lead. If someone takes a picture of your heart and on that picture it says, hey, you're having a heart attack, the odds are pretty good you're having a heart attack. But if it's negative, it's not— you're not having a heart attack, it's just a non-conclusive finding. It doesn't really tell us a lot. And anyone, any EMS provider or paramedic or emergency room physician would probably agree, if you have a 12-lead that doesn't have any heart attack on it but your patient looks like they're having a heart attack, you're gonna Treat it like a heart attack. So that's kind of why I have the language acute neurologic deficits is because we have poor examiner resources when it comes to this topic. But one of the things we're really going to talk about, because this frames the idea of patient assessment and how we talk about these acute neurologic deficits, we have to understand that your— Vasculature gets injured sometimes, and the language I use for that is something called a steno-occlusive pattern. All I'm saying when I say a steno-occlusive pattern is there's narrowing of the lumen. A steno-occlusive pattern injury and a thrombosis are not mutually exclusive. Sometimes they're together, sometimes they're independent of each other. There's a lot more nuance between An intimal tear, and in this case, like a VBA, or in an internal carotid, an intimal tear and a thrombosis. Sometimes you can get a thrombosis because of an intimal tear. Sometimes the intimal tear can cause positional ischemia. There's a lot of variability in the presentation here. But the thing that this slide I really want to talk about is this CHURCH study, which is a meta-analysis of Chiropractic and cervical artery dissection. So it includes both internal carotid and the VBA. These are relatively uncommon instances. So, okay, these rarely happen. 2 to 3% of 100,000 patients and 1 to 1.5 per 100,000 patients. That's for internal carotid and then VBA. These are wildly uncommon. But there's this idea that chiropractors, when we perform joint manipulation, sometimes will cause these things. And that's just not that simple. The reason this kind of stuff is way more prevalent, in my opinion, in the chiropractic setting is because my target audience, my target demographic in my private practice and in almost all of my peers' private practice is young middle-aged patients. I don't see a ton of geriatric patients. I see between 20 and 45-year-olds. I mean, that's like a really, really big majority of my practice. And see a lot of them for neck pain. And essentially neck pain, vertigo, headaches. I'm painting a picture of not only a great example of a stenoclusive pattern in one of those Arteries. I'm also painting a picture of my ideal patient. That's who I want to see is someone who has these kind of exam findings. Yeah. If you have neck pain, limited range of motion with some vertigo, that's who I want to see. But it just depends. And we have to do a really good physical exam to make sure that I'm not seeing one of these patients, one of these 2.5 per 100,000 patients. And it's not because necessarily my therapy is going to be bad for them because cervical manipulation, it just depends. It Could it exacerbate the complaint? Of course. Is it going to? I don't know. I don't have a good answer. But ignoring all that, I wanna make sure my patient goes to see the right provider. And if you're having a tear in your intimal wall or you're having like a stenoclusive pattern for some other reason, or like a thrombus or whatever, I want you to go see the right provider and it's not me. So this Church meta-analysis is really cool because it got to talk about, hey, we see 2.5 to 3 per 100,000 is internal carotid, and then the VBA is even less than that, 1 to 1.5 per 100,000. But our target demographic is the most likely group of people to struggle with this ischemic strokes. Now, I'm gonna touch on that real quick. This ischemic stroke, I'm not implying that it's a thrombus. I'm not applying that it is a tear in the intimal wall. It's some probably combination of that. Sometimes what can happen is you get a tear and then the irritation of that tear in the intimal wall can lead to a thrombus forming. And then a part of the thrombus will fly off and go into the circle of Willis and then up into the cerebral circulation. So I touched on this a little bit. This confounder relationship is what the Church group got after. And so if— I like teaching a ton. One of the things that I like talking about is some— this idea of a cognitive mistake.

I've tried a lot of different rubs and different types of ointments and lotions before. I used to use other topicals and never had the success that I now have with ChynaGel. ChynaGel is my pain reliever of choice. We use it in the office because of its consistency, and the response that I get from the patients is what my goal is. I want to get people better. ChynaGel allows me as the practitioner to use instrument-assisted techniques. Me as the practitioner to do ultrasound and do many different techniques that I've learned over the years in conjunction with China Gel to get the maximum benefit for a patient. It's the combination of my skills as a chiropractor and what China Gel has in it that allows the patient to get better, faster, and more effectively.

And a cognitive mistake is something like the slippery slope fallacy or cognitive dissonance or something like that, right? This is just another kind of cognitive mistake. And for anyone listening, if you do interact with patients, there's a book out there called Thinking Fast and Slow, and it's about critical thinking. It's by a guy named Daniel Kahneman. He explains a lot of these cognitive mistakes in great detail, and it is an exceptional book for healthcare providers. So Go get that. But with this confounder relationship that this CHURCH study pointed out, we know this intuitively as manual therapists. We know that people come to us with headaches, and when we treat them, sometimes they get better. And then once in a while, someone's like, hey, you caused a stroke. Well, hold on, I just see people with headaches and neck pain. I don't cause strokes. They're just coming to me, and then I'm treating them, and 1 in 50,000 or so has a stroke in progress while they're coming to see me, because that patient isn't thinking, I have a headache because I have an aneurysm in my brain. That patient's thinking, man, I have a headache and it's really bad today. I need to go see this person. I need to go see a provider to get care rendered. This confounder relationship is just really, really, really fascinating that they pointed out. To give you another more obviously incorrect example of a confounder relationship, People call an ambulance for heart attacks all the time. Ambulances don't cause heart attacks. We actually go help people with heart attacks. But when you take this heart attack and the complaints surrounding it, all— because it's not as simple as like, oh, chest pain, because that's like less than 50% of people that are having heart attacks have the complaint of chest pain. There's a gazillion different complaints that can cause chest pain. So what people in ambulances do is we cast a broad net. We test all kinds of stuff with every single patient, and based on those exam findings, we go from there. And so whenever we get these patients with headaches and neck pain and any kind of acute vestibular problem or complaint or something like that, to limit this confounder relationship, if we start casting a really broad net, We can start weeding some of these patients out. And I mean out by like weeding them into the appropriate avenue of healthcare. So this confounder's relationship is a really, really cool dynamic that this Church study pointed out. The long and short of this Church study, we're chiropractors, we treat people with neck pain and vertigo. Patients that have neck pain and vertigo also sometimes have strokes. And it's our job to do a really good job of deciding, hey, is this person just like a legit headache vertigo patient, or is this patient having some kind of cerebral event? I love that content. I love talking about cognitive mistakes because to me, it's— as a person, it's really, really, really fascinating. But this is where I get into some of the anatomy stuff, and this is where some of my continuing education courses, like, a little bit more engaged. Carotid artery dissection. We all know carotid artery goes up to the Circle of Willis. It's one of the main arteries that perfuses the brain, anterior circulation. So this is not black and white Circle of Willis. It's like a little bit more— not to be punny, but like a little more circular than that. That's like the, the amazingness of that vascular structure is that it feeds itself if something's compromised. But generally, when we have patients that are having carotid artery dissection, you get ipsilateral neck pain or headache, which if you guys remember, I know in chiropractic boards they talk about Horner's syndrome. So that's like eyes watering, pupil dysfunction, flushed skin. That's all cranial nerve stuff, right? So like carotid artery dissections typically begin with ipsilateral neck pain or headache as a partial Horner's syndrome followed by retinal Cerebral ischemia. So again, this is just classic carotid artery disease, is as basic as cerebral ischemia. It's affecting the first handful of cranial nerves, like the eyes. Basic headache stuff. Sudden onset. It's usually unilateral because you're— it's the unilateral structure. Or I shouldn't say— I should say it's a bilateral structure, but the injury is unilateral, if that makes sense. So, in my 3rd bullet, dissections are complicated by pseudoaneurysm formation. So, what I'm talking about there is when you have this stenoclusive pattern, sometimes you can get bulging of that artery. Arteries are high pressure. When you start damaging them, they can swell. Well, that internal carotid artery and all of those cranial nerves that I've Got down there. They're all really, really close together, and they make up a plexus that is around that artery as the artery— or I should say, the artery descends, but the cranial nerves descend. But they're all married together as they go down into the neck, and you can see that on that diagram. But when you start changing the shape of the artery or traumatizing the artery or something like that, you're going to irritate those nerves. And so that can look like a lot of things, but the most common one that we associate with Acute neurologic deficits is things like slurred speech. So that's a really, really common complaint in these demographics is like slurred speech, facial droop, somewhat like on the corners of the lips, maybe facial droop. But these patients, it's hard when this person walks in the room, hey, I have neck pain. I have some like facial, I can't like smile. These, some of these complaints can be really, really vague and they can on the surface sound like someone who's a really good fit for chiropractic. Chiropractic care. And if you're not doing a really thorough, rock-solid physical exam, you're never going to catch it because in your mind, hey, this is a neck pain with headache. I've seen a handful of these today. It's really simple. Wham, bam, there you go. But it's not that simple because it's actually an internal carotid dissection, which, like we talked about, is a little bit more common than your VBA. But the thing that I want to take home from this slide is this is anterior circulation stuff. So you're talking about the frontal lobe, you're talking about all your visual cranial nerves, and then you're talking about the last couple cranial nerves that follow as that internal carotid artery comes up. Those cranial nerves are following it down through the neck. So VBA ischemia is similar and They can look a lot alike, but it just depends. It's, it's just not that simple because it's a circle of Willis. It's like a big circle and it all feeds itself. But conversely, VBA dissections generally are back of the head headaches with posterior circulation ischemia. So what's back there? Well, the cerebrum. Like, what I tell my paramedic students when we're talking about head trauma is like Oh, you're looking at— that's like your vital signs area. That's like, how do you stand up? How do you breathe? Like all that brainstem balance, all that stuff is back there. So when you get ischemia to that cerebellum, you're going to have ataxia, gait problems. You're not going to be able to sit upright. You're going to have vertigo. All of that stuff can be a really big deal. You can get spinal cord infarctions as well. It just depends. When you get damage to this artery, it's usually— I should— I'm going to lump these 2 together to make this even easier. So like, as these arteries go up into the brain, they make a bunch of weird wacky bends to get up into there because it's kind of cramped. So as these arteries go up into your brain, both the internal carotid and this VBA, when they make these weird bends, that creates turbulence and pressure. I shouldn't say pressure, that creates turbulence and not a super smooth path for blood to travel. So over time, if those arteries get really stiff or irritated, voilà, you have a tear or you have damage to that artery. That is classically an aneurysm. That's like what an aneurysm is, is it's a tear in the intimal wall. But there's a lot of other types of aneurysms too. Both of these aneurysms that I'm talking about are this intimal tear, and they're not like a saccular aneurysm or like a AAA that's like a big swollen nasty thin-walled water balloon waiting to pop. This is like something that's positional. So if you can imagine, when I'm looking forward, that intimal tear is in a position where it's not stenoclusive, but when I get put in something like a declines position, Or any kind of your VAT tests, that's the whole purpose, is to put that little intimal flap into that position to produce ischemia of probably the cerebellum. So, and to kind of exacerbate those complaints. Here's the problem with some of this, and this is my second point on this, is a lot of these intracranial Aneurysms are associated with subarachnoid hemorrhage. So what that means is you get blood in that subarachnoid space, and that's a major problem, not only because you have ischemia, because now that blood is not going to the space that it needs to go into, but you have a space-occupying lesion in your brain. I don't know if it's a lesion, but you have a space-occupying mass in your brain that has a blood pressure of 120 over 80. Getting pushed up into your brain with every single heartbeat. So it's not as simple as saying, oh hey, you have some neurologic stuff, I'm not really sure, why don't you go see your primary care doctor? Because it can't— these can turn into really, really significant things that kill people. Every paramedic or EMS provider has a story of someone who had a headache and it seemed like a headache at first, and then 10 minutes later they're like snoring and halfway dead with a blood pressure of 300 because they have a big space-occupying mass in their brain that can't get under control because you can't— it's hard to stop that. Those intracranial hemorrhages are a really, really big deal, and they can happen in both internal carotid or they can happen in the VBA. If I remember the literature right, I think the most common— and this is a saccular aneurysm, it's not an intimal tear— but I think the most common aneurysm over all the aneurysms in your brain that are intracranial is in that anterior anastomosis. So, On where like your 2 anterior cerebral arteries marry, or maybe it's the anterior communicating arteries, another way to say that. But like, that's the most common place, and that's where people get like the classic, oh, all of a sudden I can't see, my head hurts, it's the worst headache ever, and all that stuff. So that can be a rupture of that saccular aneurysm. So this is the stuff that I love the most. I love talking about this content because to me, we have the coolest scope of practice. We get to be portal of entry physicians. I don't have a ton of risk. I get to spend a lot of time with my patients. I'm not like— I have so many cool pros to what my private practice looks like as a chiropractor that I take it really, really seriously when it comes to physical exams because that's like what I do is I— my hope in my practice is to master physical exams and understanding confounders relationships and what the specificity versus sensitivity is of the exams that I'm doing is just Really, really, really important. So here's how this works. In most of healthcare, you get this casting of a broad net with lots of complaints. So I'm going to give you an example. Let's say abdominal pain. Abdominal pain is like a really nightmare complaint for a lot of MDs out there, especially when they come to the ER, because it's like, well, what's abdominal pain? It doesn't mean anything. It could be A heart attack. It could be a AAA. It could be nothing. It could be low back pain. I mean, there's like a lot of things that it could be, but the complaint is really vague. So what do they do? Well, the first thing they do is they need to rule out the big stuff. They need to make sure it's not a AAA. They need to make sure it's not a heart attack. They need to make sure it's not a GI bleed. They need to make sure it's not the stuff that's going to kill people, like right off the bat. Unfortunately, in chiropractic, we don't have a ton of that stuff. We don't have a ton of things that are like, hey, this is going to kill you right off the You might see a AAA and low back pain, but in my opinion, cervical pain, neck pain, that's the stuff. That's how these stenoclusive pattern intimal tear style injuries happen or present, as they present with neck pain and some other acute neurologic dysfunction or deficit. And so as soon as your patients say something like that, How I frame it is it's like a magic word. As soon as they say, I've got neck pain and some other associated neurologic deficit, they're gonna get certain physical exam stuff, certain orthopedic tests. They're gonna get a really specific— not, I don't mean that in like the specificity sensitivity way, but like they're gonna get an order of operations from me to help rule in or out This potential acute neurologic deficit. And so, as some of you— I think I saw someone on this chat say they're in chiropractic school, so you probably have looked up some of the sensitivity and specificity of orthopedic exams, and they're just not that good. But if you're in school, go look up the sensitivity and specificity of the Cincinnati Prehospital Stroke Scale. It's actually pretty good, and that's the kind of stuff that needs to be set up in a hierarchy to paint an accurate clinical picture of presentation, because frankly, that's all I got. I have to do things in a way that puts the most sensitive and specific exams at the forefront of my care when patients say things like, oh, I have neck pain, I have a little bit of vertigo, because I have to rule out the big stuff first. So that is how I've centered my continuing education course about— it's like How do we structure these physical exams to make the most sense, to do the best job ruling stuff in and out? The only way you can really rule something in or out is with an MRI or a CT. But like, you have to have some of those big tools ready when you're in the hospital setting, because those patients— it is common for people to come into the hospital with a stroke. I don't work at a hospital. I have a private practice in the setting and like the context of a gym. So I have to be even more careful with these patients because I don't have access to a vascular surgeon and I don't have access to really much anything. If we're going to combat this confounder's relationship, we need to be really sensitive with who we're rendering care to. And we also need to be really sensitive with Who's passing and failing what exams? Because let's say you do some kind of declines test or VAT test. If your patient fails that, well, that doesn't tell you anything. It's a non-conclusive finding. The sensitivity and specificity is terrible. But what does that actually mean? It's not that it's a garbage test at all. It actually just means that, hey, you need to treat this Even more like a stroke. It's not like a negative finding on those is oh they don't have a stroke. It's like well all that's testing is there's probably not an intimal tear at the third section of the VBA of the right side or whatever side you chose to test. There's tons of other areas they can have aneurysms and there's tons of other types of aneurysms they can have that would not get aggravated with a VAT test. So all you're saying is like. Hey, now I really don't know. I thought I kind of knew, which is why we did this exam. Now I really don't know. And now you really need to get a CT or an MRI and go be seen by a physician who can get those to you quickly. In my class, I talk about when is it appropriate to call 911 versus say something like, hey, you should go see your primary care doctor. But like, there are times where it's more appropriate to say, hey, you need a 911 versus say, hey, why don't you just follow up with your primary care doctor? It just depends. idea of the confounder's relationship relative to neck pain and some of the other signs and symptoms of acute neurologic deficits. Sometimes those acute neurologic deficits are from things like a VBA dissection. Those can be from things like an internal carotid dissection. There are a lot of things that can cause that. And because we don't have any diagnostic tools, the best way to combat that is to do just a rock-solid physical exam. And understand how to interpret the results. What am I actually ruling in and what am I ruling out? And what does ruling out mean when it comes to patient care? Because it's easy to say, oh, you ruled this in. Let's take an ACL. When we do the drawer test for the ACL, well, if you go way back with the drawer test, that's unstable. I know what to do with that. That's a positive finding. But if your patient has a negative finding but they still have pain, that's like a little bit more gray, that's a little bit more complex. Anyways, my goal for this is to clear up that confounder's relationship, help people understand some of the stats and the presentations of a VBA versus an internal carotid, and then how to start talking about how do we make these exams a little bit more bulletproof. That's my hope that you guys got out of this brief talk.

Alright, guys, that's it for today's episode. Be sure to tune in for episode 36, where we dive into the second half of our training on acute neurological deficits. In our next episode, we further discuss the signs and presentations of both anterior and posterior circulation ischemia. And learn how to put these into context with current chiropractic research to help better structure and interpret your patient assessment. Guys, this information is absolutely fascinating, and I highly recommend you click the link in our show notes to watch the webinar presentation so that you can see the full visuals that go along with today's training. You won't want to miss it. Episode 36 drops in 2 weeks. You can subscribe to The Factor Podcast on Apple, Spotify, iHeartRadio, Or the podcast app that works best for you. Please give us a 5-star rating to help us grow the show. Every little bit helps. And last but certainly not least, be sure to visit the show notes for a link to download the PDF of today's full presentation, as well as learn about any special offers that we featured in today's episode. We'll see you next time. Hey guys, if you like what you heard today, I encourage you to visit our website at factor-store.com. That's spelled F-A-K-T-R-store.com to find out more information about all that we have to offer. We have a variety of online offerings as well as our hands-on FACTOR Rehab System course scheduled in cities around the globe. Be sure to also check out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future so you can join us live. And of course, the biggest compliment we can receive is for you to help us Spread the word to your friends, colleagues, and classmates. You'll find all the important links as well as info about our sponsors in the show notes, so be sure to check those out.