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
http://www.sciencedirect.com/science/article/pii/S1356689X13001926
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, (
http://www.healthcheck.nhs.uk/).
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.
http://www.csp.org.uk/frontline/article/second-opinion-exercise-life
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.
http://nvmt.fysionet.nl/ifompt/ifompt-examination-cervical-spine-doc-september-2012-definitive.pdf
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 ???
http://www.nice.org.uk/nicemedia/live/13561/56015/56015.pdf 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 ...
http://www.ncbi.nlm.nih.gov/pubmed/23021565
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
http://www.physiospot.com/research/vascular-profiling-should-manual-therapists-take-blood-pressure/
For more information on blood pressure measurements go to:
http://www.cpptjournal.org/pdfs/members/fulltext/2011/june/blood_pressure.pdf
Author
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.
https://twitter.com/TaylorAlanJ
References
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.
http://nvmt.fysionet.nl/ifompt/ifompt-examination-cervical-spine-doc-september-2012-definitive.pdf
