Alan Taylor MSc MCSP Roger Kerry MSc MMACP MCSP

Trondheim 2013

Cervical spine risk assessment

Guidance for safe & effective clinical practice Part II

IFOMPT International Standard for screening the cervical region prior to orthopaedic manipulative

Physiotherapy intervention Quebec 2012

The future?

Case Studies

CASE 1: 45-year-old male 2 months of symptoms, worsening. Relates to car accident when there was a mild shunt from behind. - Headache +dizzy on lying down and rolling in bed; - Spinning of room lasting only seconds - Nausea++; - no aural symptoms Health - fine

Differential Diagnosis Reasoning - Likelihood of a vascular Red Flag? HIGH LOW - If HIGH, can you identify the probable pathology?:________________________________ - If LOW, provide two possible alternative diagnoses: 1) ___________________________________ 2) ___________________________________ - Can you manage this patient with Physical Therapy as a primary management strategy? YES NO - Comments of differentiation (supporting/negative evidence): ____________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Differential Diagnosis Reasoning - Likelihood of a vascular Red Flag? HIGH LOW - If HIGH, can you identify the probable pathology?:________________________________ - If LOW, provide two possible alternative diagnoses: __________________________________ __________________________________ - Can you manage this patient with Physical Therapy as a primary management strategy? YES NO - Comments of differentiation (supporting/negative evidence): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

CASE 4: 42 year old male -Neck pain (to jaw) / headache (side) 1/12 -History of migraines but “not had this type of pain before” -Thinks he “pulled muscle” in throat because has difficulty swallowing food/drink. Health -High BP; been doing “McKenzie” neck exercises = worsening.

Background to differential reasoning

Pattern Recognition

VBA Dysfunction

ICA Dysfunction

NMS Dysfunction

UCI

Small vessel disease

Associated vestibular

dysfunction

Sensori-motor

Dysfunction

Other Red Flag (Ca,

metabolic, infection

etc)

A new way of approaching the problem!

APA Guidelines 2000 (2006)

www.apa.com

Evidence Base

MACP Framework

www.macp-online.com CLINICAL

REASONING

Future directions …. Why?

• Much debate over the past decades regarding: – Risks associated with cervical treatment e.g.

Manipulation/mobilisation – Examination of the cervical region for a vascular

component to clinical presentations

• Confusion for clinicians

• Time for a paradigm shift?

Objective (IFOMPT)

• To provide an update on current thinking to inform practice when examining a patient presenting with cervical spine dysfunction – Cervical Artery Dysfunction – Rushton A, Rivett D, Carlesso L, Flynn T, Hing W, Kerry R

• International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention

Aims of the IFOMPT framework

• To provide guidance for the assessment of the cervical spine region for potential of Cervical Artery Dysfunction (CAD) in advance of planned Orthopaedic Manual Therapy (OMT) interventions

• Consensus document to be agreed by 22 IFOMPT countries (2012)

Sections of the IFOMPT framework

1. Context to assessment of the cervical region 2. Clinical reasoning as a framework 3. Patient history 4. Planning the physical examination 5. Physical examination 6. Risk v benefit analysis 7. Flowchart of clinical reasoning 8. Informed consent and medico-legal framework 9. Safe OMT practice, including emergency management of an adverse

situation 10. Teaching OMT for the cervical region 11. Proposed response to the media: key messages to communicate 12. References

How will patients present to you?

How will you proceed?

Pattern Recognition (nCAD 3,4,5)

p(VBA Dysfunction)

p(ICA Dysfunction)

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Class 3: Pre-ischemia

Somatic symptoms

(pain) +/- peripheral

neurology

Class 4: Early-ischemia Transient

brain ischemia /

cranial neurology

Class 1: NMS pain with no or

minor vascular risk

factors

Class 2: NMS pain

with moderate /

high vascular risk factors

Class 5: Late-ischemia with

frank brain ischemia and

associated neurology

The Nottingham CAD Classification Model

VBI Test ?+ve

VBI Test-ve

3/11/2013 24

Class 3: Pre-ischemia

Somatic symptoms

(pain) +/- peripheral

neurology

Class 4: Early-ischemia Transient

brain ischemia /

cranial neurology

Class 1: NMS pain with no or

minor vascular risk

factors

Class 2: NMS pain

with moderate /

high vascular risk factors

Class 5: Late-ischemia with

frank brain ischemia and

associated neurology

Assessment

Treatment

3/11/2013 25

The Nottingham CAD Classification Model

Class 1: NMS pain with no or

minor vascular risk

factors

Class 2: NMS pain

with moderate /

high vascular risk factors

Treat

Class 3: Pre-ischemia

Somatic symptoms

(pain) +/- peripheral

neurology

Class 4: Early-ischemia Transient

brain ischemia /

cranial neurology

Class 5: Late-ischemia with

frank brain ischemia and

associated neurology

Refer

= Pain

= Brain ischemia

Neurological examination (IFOMPT)

• Examination of; – peripheral nerves – UMN – cranial nerves

… will assist in evaluating the potential for neuro-vascular conditions see Fuller [2008] for a detailed description of how to perform testing or www.neuroexam.com

4. Planning the physical examination (IFOMPT)

• Careful planning of the physical examination is required

• In particular for the IFOMPT framework …

• “The possible vasculogenic (cervical arterial)

contribution to the patient’s presentation needs to be clearly evaluated from the patient history data”

IFOMPT (cont’ …)

Are any further patient history data required? • An important component of planning is the

identification of any further patient history data that may be required – Are there any gaps in the information obtained? – Is the quality of the information obtained

sufficient?

http://creativecommons.org/licenses/by-sa/2.0/deed.en

IFOMPT on …. Physical examination - Decision-making

• The physical therapist needs to decide: – Are there any precautions to orthopaedic manual

therapy (OMT)? – Are there any contraindications to OMT? – What physical tests need to be included in the

physical examination? – What is the priority for these physical tests for this

specific patient? – Do the physical tests need to be adapted for this

specific patient?

More questions than answers . . . !

Physical examination • Blood pressure

• Cranial nerve examination • Pulse palpation/auscultation • Eye examination • Proprioception tests (Romberg’s; Tandem gait) • VBI test? • Instability testing? • US Doppler??

Physical examination (Kerry & Taylor) • Blood pressure

• Cranial nerve examination • Eye examination • Pulse palpation/auscultation • Proprioception tests (Romberg’s; Tandem gait) • VBI test • Instability testing? • US Doppler??

Blood pressure?

• Is it part of your examination?

• Case study …. NOT RCT!!

Cranial nerves?

• Upper limb?

• Lower Limb?

• UMN?

• Cranial nerves . . . Are they part of your examination?

CRANIAL NERVES 2’ EXAM!

http://www.youtube.com/watch?v=eLzkgPkgkEo

“Cranial nerves . . . That would take forever!!”

What is physiotherapy?

• “Physiotherapy is a health care profession concerned with human function and movement and maximising potential:

• it uses physical approaches to promote, maintain and restore physical,

psychological and social well-being, taking account of variations in health status

• it is science-based, committed to extending, applying, evaluating and

reviewing the evidence that underpins and informs its practice and delivery

• the exercise of clinical judgment and informed interpretation is at its

core.”

Neck rehab …. ?

Are we ‘maximising potential’ …. ?

Are these Muscular Changes a

Unique Feature of Persistent WAD?

But questions remain….

…muscle changes have been quantified

Elliott et al., 2006, 2008, 2009, 2010, 2011

T1-weighted Axial Magnetic Resonance Image at the C6 vertebral level demonstrating outlined regions of interest for the right and left longus colli and the right and left posterior cervical

multifidus.

Increased signal, indicative of fatty infiltration, is noted in both sets of muscles in a subject with chronic WAD

posterior

Falla, Elliott, Jull, 2010

Idiopathic Neck Pain

23

Whiplash

79

Average Fat < 0.24

Classification tree illustrating the determination of the condition based on average MRI fat in cervical extensor musculature

Dx + Dx -

79 0

0 23

Elliott et al., 2008

Fatty infiltrate in the cervical extensor muscles is not a feature of chronic, insidious-onset neck pain.

Altered muscle recruitment patterns: Cranio-Cervical Flexion Test (CCFT)

Jull et al 1999, Cephalagia Jull et al 2000, J Musc Pain Falla et al 2003, Phys Ther Falla et al 2003 Man Ther Falla et al 2004, Disab Rehab Falla et al 2004, Spine Jull et al 2004, Man Ther Uthaikhup and Jull 2009 Man Ther

Local cervical mechanical hyperalgesia

Kasch et al 2001, Spine Kasch et al 2001, Cephalagia Sterner et al 2001, J Spinal Disorders Sterling et al 2003, Pain O’Leary et al 2009, J of Pain

(Sterling 2004, Man Ther)

Generalised sensory hypersensitivity (mechanical, thermal, BPPT)

Koelbaek-Johansen et al 1999, Pain Curatolo et al 2001, Clin J Pain Sterling et al 2002, J Musc Pain Sterling et al 2003, Pain Chien et al 2009, Man Ther

The future . . . ? Cervical sensorimotor assessment and management

• Cervical spine JPS or error (JPE) • Oculomotor (gaze; eye movement) • Postural stability

Increased JPE (Joint Position Error)

Revel et al 1991, Arch Phys Med Rehab Loudon et al 1997, Spine Kristjansson et al 2003, Clin Rehab Treleaven et al 2003, J Rehab Med De Hertogh et al 2007, Cephalagia Hill et al 2008, Man Ther Sjolander et al 2008 Treleaven 2008, Man Ther

Head movement

Eye movement

Sensorimotor Approach to Understanding WAD

Relies on:

Visual Vestibular Proprioception (Cervical)

Stable

Upright

Rehabilitation …. ?

Balance/proprioception . . . !

www.sportsphysio.ie/balance.htm

Functional Exercise

www.physioadvisor.com.au/8119350/knee-strengt...

SUMMARY

•WAD patients show objective evidence of muscle changes on MRI

•Whiplash injuries are different from non-traumatic neck pain

•Fatty infiltration occurs only in whiplash patients

•The cause and exact timing of this phenomenon remains unknown

•There may be a case for sensorimotor assessment of patients Elliott J, Jull G, Noteboom JT, Galloway G. MRI study of the cross-sectional area for the cervical extensor musculature in patients with persistent whiplash associated disorder (WAD). Manual Therapy 2008;13:258-265. Elliot J, Sterling M, Noteboom JT, Darnell R, et al. Fatty infiltrate in the cervical extensor muscles is not a feature of chronic, insidious-onset neck pain. Clinical Radiology 2008;63(6):681-687. Elliott J, Pedler A, Kenardy J, Galloway G, Jull G, Sterling M. The temporal development of fatty infiltrates in the neck muscles following whiplash injury: An association with pain and post traumatic stress. Plos one. June 2011, vol 6(6) e21194, www.plosone.org

References; Sterling M, McLean SA, Sullivan MJ, Elliott JM, Buitenhuis J, Kamper SJ.. Potential processes involved in the initiation and maintenance of whiplash-associated disorders: discussion paper 3. Spine (Phila Pa 1976). 2011 Dec 1;36(25 Suppl):S322-9 Elliott JM. Are there implications for morphological changes in neck muscles after whiplash injury? Spine (Phila Pa 1976). 2011 Dec 1;36(25 Suppl):S205-10 Treleaven J, Jull G, Grip H. Head eye co-ordination and gaze stability in subjects with persistent whiplash associated disorders. Man Ther. 2011 Jun;16(3):252-7. Epub 2010 Dec 23.

JOSPT Neck Special Edition May 2009 39(5)

LETS USE THE EB TO GET

SMARTER WITH OUR

MANAGEMENT

Download IFOMPT CAD Guidance Document, assessment details &

references from:

http://www.ifompt.com/

3/11/2013 58

Thank You

Questions

The Pulse of Thought: Haemodynamics of the Brain and Mind

Thanks for your feedback . . . ! Roger.kerry@nottingham.ac.uk alan.taylor@nottingham.ac.uk

@TaylorAlanj