Cervical Artery Dysfunction (CAD) – Improving safety amongst MSK Physiotherapists


Due to changing healthcare systems, more Physiotherapists are working as front-line practitioners and managing complexity. Physiotherapists need appropriate training and skills to ensure safe, effective care is delivered. Screening for CAD was an identified training need for Nuffield Health Physiotherapists. Although rare, vascular pathologies are complex and if managed incorrectly can have life-changing impacts on patients and their families. In September 2018, the Nuffield Health Academy launched an educational programme to address this training need. Educational programme: E-learn including lessons on anatomy, CAD pathology, risk-factors, symptoms, assessment and onward-referral. A case-study highlighting key learns from a patient presenting to Nuffield Health with CAD. The primary aim was:

1. Improve Safety by influencing appropriate clinical escalation of CAD (behaviour change).

Secondary aims included:

1. Raising the awareness and understanding of CAD.

2. Develop confidence and clinical reasoning when screening suspected cervical red flag and/or vascular pathology.

4 cases of CAD
Were confirmed after urgent clinical escalation.


This mixed-methods programme evaluation investigated how successful our educational programme was at meeting the intended aims. Retrospective data was collected from a central register recording urgent clinical escalations and suspected red-flag pathology. All CAD-related entries were recorded from the 12-month period prior to, and post launch of the educational programme. Physiotherapists were blinded. A questionnaire was sent to all Nuffield Health Physiotherapists 12-months after the educational programme release. The questionnaire was voluntary and captured quantitative and qualitative data.


Results: 433 Physiotherapists completed the e-learn. A 13-fold increase in urgent clinical escalation and reporting of suspected CAD was observed in 12-months following launch of the educational programme (12-months prior: 2, post: 27). 4 cases of CAD were confirmed after urgent clinical escalation. 120 Physiotherapists completed the questionnaire (response rate: 28%).

· 97% agreed (61%) or strongly agreed (36%) it increased understanding and/or awareness of CAD.

· 87.5% agreed (58%) or strongly agreed (29.5%) it made them a safer Physiotherapist when assessing neck pain and/or headaches.

· 85% agreed (58.5%) or strongly agreed (26.5%) it improved confidence in cervical red-flag screening.

· 82.5% agreed (69%) or strongly agreed (13.5%) it helped clinical reasoning and differential diagnosis of neck pain and/or headaches.

Thematic analysis identified 6 themes; 1. Valuable resource, 2. Appetite for further training, 3. Useful refresher of knowledge, 4. Should continue as role-essential training for MSK Physiotherapists, 5. Raised awareness and confidence, 6. Suggestions to improve training.

Conclusion(s): The findings suggest that a targeted educational programme can lead to improved safety behaviours amongst MSK Physiotherapists. We demonstrated that our educational programme improved understanding and awareness of CAD, confidence when screening for cervical red flags and helped clinical reasoning.

Cost and savings

No specific costs other than salaried time.


At organisational level, this programme evaluation demonstrated value in continuing delivery of our CAD e-learn. It promotes safe Physiotherapy practice and reduces the risk of harm to patients. It offers opportunities to improve our educational offering and consider how to meet the appetite for further education in this field.

Considering wider impact, this programme evaluation supports the notion that education is a conduit for behaviour change. It provides an opportunity to contribute to the wider understanding of CAD through future research and case-study publication.

Top three learning points

No further information. 

Funding acknowledgements

This programme evaluation was unfunded. The author is an employee of Nuffield Health and all time used to design methodologies, collect data, analyse and write-up was completed within salaried hours.