Original articleInternational framework for examination of the cervical region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy intervention
Introduction
Cervical Arterial Dysfunction (CAD) in patients presenting with neck complaints is a rare event, but a critical consideration as part of a comprehensive Orthopaedic Manual Therapy (OMT) assessment. Vascular pathologies, such as arterial dissection, are generally recognisable if appropriate questions are asked, data is interpreted correctly during the patient history, and if the physical examination is adapted to test a potential vasculogenic diagnostic hypothesis. An important underlying principle of the patient assessment is that physical therapists cannot rely on the results of one test to draw conclusions regarding the presence or risk of CAD, and therefore development of a clinically reasoned understanding of the patient's presentation, including risk:benefit analysis, following an informed, planned and individualised assessment is essential. There are multiple sources of information available from the patient assessment that can assist clinical reasoning and the confidence of estimating the probability of the patient presenting with or developing CAD. The provision of specific, prescriptive guidance is limited by the inadequacies of the current evidence base (that will progress with ongoing research), and therefore manual therapists need to critically appraise the literature and combine this with their own clinical experience and patient preferences to facilitate optimal clinical decision-making for each patient individually.
In 2008, the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) convened an expert working group to create a resource for best practice in cervical region examination in individuals with neck complaints that may present with CAD or be at risk of developing CAD. The vision statement of IFOMPT is the “world-wide promotion of excellence and unity in clinical and academic standards for manual/musculoskeletal physiotherapists”, reflecting an international organisation aiming to promote and maintain high standards of specialist education and clinical practice, promote and facilitate evidence based practice, communicate widely the purpose and level of the specialisation, and to work towards international unity/conformity of postgraduate educational standards of practice. As of 2013, IFOMPT consists of 22 Member Organisations (MOs)/countries meeting IFOMPT's documented standards in postgraduate education in OMT and 11 Registered Interest Groups (RIGs) aspiring to the same.
The aim of the framework development was to guide clinical reasoning for the assessment of the cervical spine region for potential of CAD prior to planned OMT interventions focussing on techniques occurring in end range positions, notably during passive joint mobilisation, exercise, and high velocity thrust manipulation interventions. The framework is designed to be reflective of best practice, intending to place risk in an appropriate context that is informed by the available evidence. In this context, the framework considers both ischaemic and non-ischaemic CAD presentations to identify risk, prior to any overt symptoms and signs in a patient presenting for cervical management. The framework is designed to be informative, not prescriptive and is intended to enhance the clinician's clinical reasoning as part of the process of patient assessment and management. The framework is not complex, but it is flexible; allowing the clinician to apply it based on an individual patient's presentation and preferences, thereby facilitating patient-centred practice.
Section snippets
Project group
An international collaboration of the Standards Committee of IFOMPT and invited international subject experts.
Stage 1
The issues central to the framework were initially explored at the World Confederation for Physical Therapy Congress (June 2007, Vancouver). An IFOMPT coordinated session focused on vertebrobasilar insufficiency, an issue that had generated many questions from MOs of IFOMPT and individual physical therapists. The session generated robust discussion related to pre-manipulative screening
Findings
Consensus and approval of the framework by the 22 MOs of IFOMPT was achieved in October 2012 at the IFOMPT Conference in Quebec City. The framework is based on best available evidence at the time of writing, and is to be used in conjunction with the IFOMPT Standards (IFOMPT, 2008) and with the key literature sources identified. Central to the framework are sound clinical reasoning and evidence based practice. The framework is divided into key sections which are outlined below. The complete
Discussion
It has been a challenging process to produce an international agreed framework; emphasising the importance for MOs of IFOMPT to now operationalise the framework in line with their national legislative, regulatory, and professional bodies in order to support individual clinicians. The framework is structured to enhance the clinician's clinical reasoning to be an aid to patient-centred clinical reasoning. A generic flowchart of clinical reasoning is provided rather than a prescriptive algorithm.
Conclusions
The purpose of this framework is to guide the clinician's process of assessment of the cervical spine to evaluate the potential for CAD. An informed, planned and individualised assessment of the patient is advocated, with multiple clinical findings combined to inform a risk:benefit analysis regarding management. CAD is an area of increasing interest and the evidence base continues to develop. Therefore, this framework will be reviewed and updated within 5 years.
Acknowledgements
The following organisations for permitting the authors to adapt their existing work with permission:
Canadian Physiotherapy Association's Manual Therapy Steering Committee
Musculoskeletal Association of Chartered Physiotherapists, United Kingdom (formerly the Manipulation Association of Chartered Physiotherapists).
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