Thursday, 19 December 2013

Twitter in Physiotherapy education: Exciting prospect or lame duck?

Reflections on TWEED13 @University of Nottingham

The University of Nottingham’s ‘Twitter in Education Conference’ TWEED13 took place on December 16th 2013. The mini-conference raised a number of interesting issues and potential directions for the future. 

Roger Kerry @RogerKerry1 (Division of Health Sciences) and Natasa Lackovic @natasa_wonders (Learning Sciences Research Institute) presented their experiences of attempting to engage 43 Physiotherapy (PT) students in a Twitter based project to promote engagement with the evidence based practice (EBP2) module.

In short … Despite the news that recent research from @pewinternet shows Twitter's influence has doubled amongst (US) teens. Nottingham’s PT students did NOT engage!
This may come as a surprise to some and a no brainer to others.

So why not? ... I hear you asking. 

Whilst is well known that students spend many hours on social media platforms; it seems they are spending the bulk of it on Facebook and only a small proportion of it on Twitter. 

As it turned out that only 12/43 students in the Nottingham cohort actually were Twitter users prior to the study. Subsequently, next to no local students took up the cudgels. However, there did seem to some take up of the #EBP2 hashtag from other academics and interested parties and PT students other Universities.

So what does this tell us? … and what are the directions for the future? Well it seemed in this one small study that students simply didn’t ‘get it’. The conference perhaps provoked more questions than answers. Such as;

‘Should lecturers be incorporating this technology into lectures to illustrate its worth?’

‘Is the whole thing simply distracting anyway… and would we be better without it?’

So what are the barriers to Twitter use in education?


“I would never use Twitter for learning” (UoN student)
“I don’t want to follow lecturers … They might look at what I post” (UoN student)
Twitter novices "fear of saying something inadequate / embarrassment"
Twitter is perceived by students to be "not for students"
‘I have encouraged some colleagues onto Twitter for CPD but they are resolute lurkers.’


Potential tweepy solutions


Provide social media training/induction? … to highlight how and why they might want to use social media avenues for their studies.

Use a ‘professional’ Twitter pseudonym … a tactic commonly used in business, music and education. It is not uncommon for individuals to have multiple ‘profile/personalities’ on social media. This eliminates the student’s  worry of lecturers ‘seeing their silly tweets’.

Encourage ‘lurkers’ … It is often possible to learn a great deal from the posts, debates and discussions of more confident engagers without EVER entering into the conversation.

Use of twitter for providing student feedback (via the private message facility - 140 characters) … The beauty of this, is that it HAS to be short and to the point … a useful writing skill at every level for students and academics alike.


#Tweed13 provided an outcome which was perhaps different from my own personal expectations. However, that in itself was entirely thought provoking. The mini-conference provoked (cyber and real) discussion and gave us some useful pointers for future directions in an emerging field within University education.  

Far from being a lame duck, this small study perhaps just illustrated we may have to be a little more inventive with regard to our own approach to innovation. I can't wait to get back on the lake again!

Watch this space tweepies!

The author @TaylorAlanJ  uses Twitter in education in a variety of ways.

Tweepy resources


Thursday, 5 December 2013

5 good reasons for manual therapists to take blood pressure

1.    Risk assessment – The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) produced a seminal consensus document for cervical spine risk assessment (Rushton et al, 2012). The accompanying paper available here
details a core shift in thinking about vascular risk and manual therapy. One of its key recommendations is that manual therapists consider incorporating blood pressure testing into their toolkit for risk assessment prior to treatment.

The concept of haemodynamic awareness is not limited to the cervical spine. It is known that simple therapeutic exercise can have haemodynamic implications throughout the body. There are systemic vascular responses to a range of therapeutic interventions such as lumbar mobility exercises in healthy subjects (Al-Obaidi et al, 2001). It is currently unknown what the responses might be in individuals with underlying pathology such as abdominal aortic aneurysm or atherosclerotic plaque. Clinicians have a duty to make appropriate risk assessment prior assessment, manual therapies or exercise prescription. The assessment of blood pressure may be a component of this process for some patients.

2.    Health Check? - In the UK, high blood pressure is one of the most important preventable causes of premature ill health and death. It is identified as a major risk factor for stroke, heart attack, heart failure, chronic kidney disease and cognitive decline. It has also been identified as a focus of the NHS ‘Health Check’ drive, (

Patients visit physiotherapy departments for a variety of musculoskeletal (MSK) complaints which may be associated with other health issues or co-morbidities. Physiotherapists should be cognisant with a patient’s blood pressure status from a health assessment perspective (Taylor and Kerry 2013). It is known that some conditions of vascular origin may mimic MSK conditions i.e. abdominal aortic aneurysm, impending stroke (Kurihara 2007).

In the United States this concept is well recognised and the American Physical Therapy Association produced a Guide to Physical Therapist Practice (2001) which made the recommendation that patient examination should begin with a history and systems review which includes “anatomical and physiological status of the cardiovascular/pulmonary system, integumentary, musculoskeletal and neuromuscular systems”. The guidance went on to say, “Heart rate and BP are measured to assess aerobic function and circulation, these measures can assist the physical therapist in identifying cardiovascular or pulmonary problems that might affect prognosis and intervention or require referral to another practitioner.”

It is an unfortunate reality however, that many clinicians do not see the relevance to their practice, which poses the question of whether they are cognisant of their unique role and opportunity, to play a part in the health and wellbeing of their patient population.

3.    Clinical Reasoning – Vascular tissue contains nociceptors and may be source of local PAIN… Manual therapists treat PAIN and should be cognisant of that within their clinical reasoning.
It is well recognised that vascular tissue and mechanisms of cervical arterial dysfunction (CAD) may give rise to pain in the cranio-cervical region (Taylor and Kerry 2005). It is perhaps less well known that vascular tissue can be the source of pain syndromes throughout the body, ranging from the obvious – abdominal aortic aneurysm (low back pain), through to the less obvious (or less well known) distal limb pain/numbness as a result of popliteal artery entrapment syndrome (PAES). PAIN may be local due to a nociceptor response in the tunica adventitia due to underlying pathology (arterial dissection, atherosclerosis, aneurysm) or distal due to ischaemia (which may be movement or exercise induced).

4.    Medico-Legal – Enough has been written in the manual therapy literature for a healthy evidence base to underpin both practice and clinical reasoning. The job of an expert witness is to assess whether a practitioner is acting according with contemporary evidence and in the way that a reasonable body of similar professionals would. Certainly in the cervical spine, the 2012 IFOMPT cervical spine risk assessment document provides clinicians with the current best evidence level and guides assessment, decision making and practice.

Elsewhere, from an anatomical perspective, there is an increasing body of literature relating to ‘altered haemodynamics’ throughout the body. What may surprise clinicians is that this work relates to a wide range of groups or profiles, from elite athletes (Bender et al, 2012) through to elderly diabetics with atherosclerosis (Chin 2014). As manual therapists are in the business of manipulating, mobilising, moving and prescribing movement based exercises there is a need to be aware of haemodynamic theory and the relevance to active and passive interventions.

Working as an expert witness in the field of clinical negligence and altered haemodynamics has raised my own awareness of the need for therapists in a range of specialties, to give consideration to BP. Furthermore, it seems and that adverse events are NOT confined to manipulation and may occur after examination or exercise prescription. This is a sobering thought and one which clinicians would be wise to cognisant of.

5.    Cos you know it makes sense!
- I haven’t got time for all these extra tests is the common cry. Well IFOMPT have cleverly suggested that you should find time! Perhaps consider re-ordering your routine physical testing. In other words, if you have an index of suspicion of CAD following the patient interview, then it may be prudent (for all of the above reasons) to consider a cursory BP check. It actually takes about two minutes of your time. BUT may save you hours!

Oh, and BP measurement is increasingly being performed by fitness instructors and Sports Rehabilitators... Don't get left behind!

... and if the results surprise you... What then ??? will help to guide your clinical reasoning. The answers are often not clear cut and should be considered on a case by case basis, when ALL of the relevant imformation has been gathered. For case by case examples see ...

KEY ADVICE - Read the salient points in the IFOMPT document ...

DON'T RELY on one single test to make your decision  (i.e. just the blood pressure values ... Unless they are dangerously high - >180/110 see NICE Clinical Guideline 127 ...

For values below that threshold ... consider the whole patient presentation and the range of potential pathologies, as described in the IFOMPT document. Specific case studies can be found at

For more information on blood pressure measurements go to:



Alan J Taylor - is a medico-legal expert witness, in the field of clinical negligence related to manual therapy and stroke or other haemodynamic events.

He has worked as a lecturer in Physiotherapy and Sports Rehabilitation & Exercise Science at the University of Nottingham since 2010.

He worked full-time as a clinician until joining the UoN and maintains a clinical case load via his Consultancy, which regularly takes him to to some of the UK's leading sports clubs. He deals with a variety of pain and performance related cases, many with a haemodynamic bias.

Al-Obaidi S, Anthony J, Dean E, Al-Shuwai N (2001) Cardiovascular responses to repetitive McKenzie lumbar spine exercises Phys Ther. 81(9):1524-33.

Bender MH, Schep G, Bouts SW, Backx FJ, Moll FL (2012) Endurance athletes with intermittent claudication caused by iliac artery stenosis treated by endarterectomy with vein patch--short- and mid-term results. Eur J Vasc Endovasc Surg. 43(4):472-7. doi: 10.1016/j.ejvs.2012.01.004. Epub 2012 Jan 20.

Chin JA, Sumpio BE (2014) Diabetes mellitus and peripheral vascular disease:
diagnosis and management. Clin Podiatr Med Surg. 31(1):11-26. doi: 10.1016/j.cpm.2013.09.001. Epub 2013 Nov 7. PubMed PMID: 24296015.

Guide to physical therapy practice. 2nd ed. Alexandria, Va: American Physical Therapy Association; 2001. P. 28.

Kurihara, T. (2007). Headache, neck pain, and stroke as characteristic manifestations of the cerebral artery dissection. Intern Med 46(6): 257-258.

Taylor AJ, Kerry R (2013) Vascular profiling: should manual therapists take blood pressure? Man Ther. 18(4):351-3. doi: 10.1016/j.math.2012.08.001. Epub 2012 Sep 25.

Taylor AJ, Kerry R (2005) Neck pain and headache as a result of internal carotid artery dissection: implications for manual therapists. Man Ther. 10(1):73-7.

Wednesday, 9 October 2013

Cranial nerve testing & cervical spine risk assessment – A ‘no brainer’!

Straw poll anyone...?

Hands up manual therapists ... if you would perform a neurological examination (upper limb/lower limb/UMN), if a patient’s subjective history indicated that you should………..
GOOD, that’s pretty much 100% of you then?

Hands up ... if you would perform a cranial nerve examination if a patient’s subjective history indicated that you should…. Mmmm, I suspect that result is well below 100% (amongst physiotherapists for sure...!)
Medical illustrations of the cranial nerves by Joanna Culley of

For decades, manual therapists worldwide, have talked about the importance of the D’s (dizziness, drop attacks, diplopia, dysarthria and dysphagia) and N’s (numbness, nausea and nystagmus) when taking a subjective history in patients’ suspected of having ‘vertebrobasilar insufficiency’ (VBI). 

In the same way physiotherapists in the UK, were traditionally taught to perform a thorough neurological examination in upper and lower limbs, in cases of suspected neurology or upper motor neurone dysfunction.

So why did we never really get to grips with cranial nerve examination in suspected cervico-cranial neurology? There’s no point in looking back really (though a few educationalists might shift awkwardly in their seats), the plain stark fact is that we have been missing a trick! The D’s and N’s we diligently worried so much about, were simply subjective manifestations of cranial nerve dysfunctions linked to brain ischaemia.

Frankly, it is that simple. A well-performed CN examination may provide key information to assist in the clinical reasoning, risk assessment and triage process. That is why it appears as a prominent part of the 2012 IFOMPT International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention ... A somewhat long winded name, for what is essentially a cervical spine risk assessment document.

The IFOMPT document was achieved via protracted International consensus and represents the best level of evidence we currently have. Therapists would be wise to avail themselves of the key recommendations for practice contained in the document. Some key points are mentioned below, BUT … the author advises reference to the complete document for balance.

Implications for practice

There are serious conditions, which may mimic musculoskeletal (MSK) dysfunction in the early stages of their pathological progression.
1.     Cervical arterial dysfunction
2.     Upper cervical instability

This basically means that manual therapists need to possess the tools by which they can make informed decisions about risk, from a subjective and objective perspective.

A comprehensive list of risk factors and differential diagnosis table is contained within the IFOMPT document (pp 13-14). There are also some useful case histories which help to put this into perspective (pp 15-16)

Clinical decision-making

Some important points are made with regard to decision making for the physical examination are also highlighted.

“Based upon the evaluation and interpretation of the data from the patient history, 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?” (IFOMPT 2012)

The above are generally normal practice for most experienced manual therapists. However, the following two items, frankly should be normal practice also, but are explicit in the document.

What is the priority for these physical tests for this specific patient? What is the order of testing and to which tests should be completed at the first visit?

·Do the physical tests need to be adapted for this specific patient?" (adapted from IFOMPT 2012)

Implications for clinicians

Well simply, there is an International guidance document, which suggests you need to think carefully about HOW TO PROCEED with your physical examination. The clinician may be wise not to launch into a ‘routine examination’ and this has obvious medico-legal implications.

What does that mean practically?

Essentially, that clinicians should, from a detailed subjective history and sound clinical reasoning, be able to adapt their clinical examination (and order of) accordingly. This may, based on the findings of the subjective history include a consideration of upper cervical instability, high or unstable blood pressure and cervical arterial dysfunction. 

A series of possible actions are described in full, in the IFOMPT document (pp 18-21)

I will draw your attention to the specific sections on cranial nerve examination and blood pressure testing (which I cover in a separate blog), which may form part of the physical examination.

Clinical pearls


1.     Cranial nerve testing is an essential part of physical examination in the presence of neurovascular signs and symptoms in the cranio-cervical region

2.     Physical examination involves movement and that alone may cause neurovascular compromise

3.     Remember, this is no longer just about the vertebral artery – USE SYSTEM BASED THINKING

4.     Cases of arterial compromise have been documented (usually as medico-legal cases) linked to EXAMINATION only! 

5.     Remember, this is no longer just about just arterial dissection

6.     Clinicians should be aware of the range of arterial pathologies and their potential links to movement based therapies NOT JUST MANIPULATION!

7.     GOOD NEWS …Physiotherapists are currently World leaders in guiding practitioners toward safe, evidence based practice and risk assessment in the cervical spine

It is in your interest as a clinician (at every level) to be familiar with IFOMPT 2012


International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention (2012)
Taylor AJ, Kerry R (2010) A systems based approach to risk assessement of the cervical spine prior to manual therapy. International Journal of Osteopathic Medicine 13(3):85-93

Kerry R, Taylor AJ (2009) Cervical arterial dysfunction: knowledge and reasoning for manual physical therapists. Journal of Orthopaedic and Sports Physical Therapy 39(5):378-387


Anatomy Video (Armando Hasudungan)

Cranial Nerves - functions and disorders 
Cranial nerves -

Physiotherapy UK Congress 2013 -

One minute medical school - Cranial Nerves  

Cranial Nerve OSCE examination 

Two minute CN Examination


Alan J Taylor  - is a medico-legal expert witness, in the field of clinical negligence related to manual therapy and stroke.

He works as an Assistant Professor in Physiotherapy and Sports Rehabilitation & Exercise Science at the University of Nottingham.

Tuesday, 16 April 2013

Andrew Marr's "exercise induced stroke" ...What have we to learn?

Andrew Marr; a case of exercise induced stroke?

Well-known political commentator Andrew Marr, recently told the story of his sudden stroke. It seems that Marr was of the belief that his stroke was ‘exercise induced’ … alarming news indeed, so alarming that the topic made the Jeremy Vine show on Radio 2! So how did he come to that conclusion I hear you ask? Marr explained that he had suffered two 'mini-strokes' – or transient ischaemic attacks – the year before, but that he "hadn't noticed" (presumably revealed by subsequent scans). He went on to make the suggestion that his stroke was triggered by a vigorous rowing machine exercise bout, that he was undergoing in response to newspaper reports relating to the benefit of high intensity training (HIT).........

Carotid artery dissection

So what happened? Well all we can say, is that Marr reported how he felt the symptoms of his stroke (“blinding head ache and flashes of light”) following the exercise where he said he "gave it everything I had" in the belief that this would benefit his health. He described how he had “torn the carotid artery, which takes the blood supply to the brain”. In other words he had suffered an arterial dissection with embolisation. He woke the next morning with what was essentially an ischaemic stroke........

NHS response

There has been much commentary since the interview and the NHS have been quick to respond and reassure patients in a factual way. Is-exercise-to-blame-for-Andrew-Marrs-stroke?

.......... Indeed, some ‘experts’ have made the suggestion that there may not have been a link between the two events. Marr had explained some of his life style risk factors such as his high-pressure job, previous smoking and a history of being overweight. So it is of course plausible that his carotid arteries were already showing signs of atherosclerotic pathology. Was there a link? Well it is impossible to say for sure, but stroke sufferers commonly report headache, neck pain and visual disturbances as their primary symptoms and this is well documented in the literature........

IFOMPT guidance on risk

The significance of this event to physiotherapists is multifactorial. As prescribers of exercise we have to have an understanding of what happened and be able to risk assess and advise patients accordingly. It illustrates also that we must consider the holistic health of patients too as part of a risk assessment strategy and this is supported by the recent IFOMPT cervical spine document. 

Cranial nerve examination?

Indeed it is feasible for such a patient (pre-ischaemia) to walk into a physiotherapy out patient department seeking treatment for their “head ache” (Marr had a window between the onset of his symptoms and his eventual stroke).  Only careful consideration of their symptoms and physical examination, to include blood pressure and cranial nerve testing, may reveal the true nature of the underlying pathology. 

Remember the acronym FAST (face, arms, speech, time – full details on the NHS website) and don’t forget to include the cranial nerves in your examination.

So, is HIT harmful?

Well the jury remains out on that one, though the balance of evidence suggests not. Whilst it would be bad science to use a single case study to promote a knee jerk reaction, Marr’s experience certainly raises the debate and once again raises the spectre of heterogeneity. 

The key message

If those commentators are right; and this was simply a stroke that was 'waiting to happen'. Then you truly never know, quite who or what might be lying on your treatment table ... Happy risk assessment! 

The author  

..... has written over 20 peer reviewed papers relating to blood flow issues related to manual therapy, his work has been cited in the IFOMPT International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention

Altered haemodynamics

Follow on twitter@TaylorAlanJ