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...!)

http://www.medical-artist.com/cranial-nerves.html
Medical illustrations of the cranial nerves by Joanna Culley of Medical-Artist.com

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.

http://tinyurl.com/bpkj2xw

 

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

References

International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention (2012) http://www.ifompt.com/site/ifompt/files/pdf/Standards%20Committee/Standards%20Committee%20Documents//IFOMPT%20Examination%20cervical%20spine%20doc%20September%202012%20definitive.pdf

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

Education 

Anatomy Video (Armando Hasudungan)


Cranial Nerves - functions and disorders 
 
Cranial nerves - http://prezi.com/l-chg-rsdkf5/cranial-nerves/

Physiotherapy UK Congress 2013 -  http://prezi.com/yv9w6ixyjbrn/cervical-spine-risk-assessment-rehabilitation-guidance-for-safe-effective-clinical-practice/

One minute medical school - Cranial Nerves  

Cranial Nerve OSCE examination 

Two minute CN Examination

Author

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. 

https://twitter.com/TaylorAlanJ

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

BMJ, Manipulating the manipulators!

BMJ Manipulating the manipulators!

What fun the BMJ are having. Take three authors will little or no track record in the field, get them to review a few 'Cherry picked' papers, write a non-peer reviewed opinion/debate article (http://www.bmj.com/content/344/bmj.e3679) add a press release (http://www.bmj.com/press-releases/2012/06/07/should-spinal-manipulation-neck-pain-be-abandoned) and light the touch paper! 

Enter the 'Daily Mail' (http://www.dailymail.co.uk/health/article-2156179/Letting-chiropractor-crack-neck-ease-pain-trigger-stroke.html), fan the flames and watch the manipulators eat themselves. Nice . . . Or is it? 

We learnt a lot in Physiotherapy about the haemodynamics of the cervical spine and risk assessment over the last decade or so. We had seen the limitations of our own 'bad science', the vertebral artery test and IFOMPT will this year provide guidance to those who treat the cervical spine in a well thought out attempt to limit risk.

Wand et al (2012) have been manipulated themselves, and whilst they clearly enjoy the spotlight (#abandonneckmanipulation on Twitter "woohoo") their argument is weak and badly thought out (see the considered respondents on the BMJ site) and furthermore is harmful to the profession. My last two (expert witness) medico-legal cases involving stroke post manual therapy, were in fact not manipulation cases, but rather ASSESSMENT CASES . . . Oh, I hear the wolves call, perhaps we should call a halt to assessment and movement too? Then we truly can stick to handing out leaflets (http://rogerkerry.posterous.com/should-cervical-manipulations-be-abandoned).

So unwittingly we (as a profession) fall into the trap set by the BMJ, we antagonise the Chiropractors/osteopaths and call our own profession into question. We have more to learn about haemodynamics and risk in the cervical spine I have no doubt . . . but is this the way to operate in what is already a challenging and hostile environment? There really is no strong scientific case for calling a halt to manipulative therapy, any more there is many components of conventional medicine. You can read the debate yourself and I would invite you to make up your own mind.

In the mean time take the opportunity to vote on the BMJ website . . . Have your say, they did . . . in the most manipulative way.

1. Kerry R, Taylor AJ, Mitchell, JM, McCarthy C. Cervical arterial dysfunction and manual therapy: A critical literature review to inform professional practice. Manual Therapy 2008;13: 278-288
2. Bowler N, Shamley D, Davies R. The effect of a simulated manipulation position on internal carotid and vertebral artery blood flow in healthy individuals. Manual Therapy 2011; 16: 87-93
3. Kerry R, Taylor AJ. Cervical arterial dysfunction: knowledge and reasoning for manual physical therapists. Journal of Orthopaedic and Sports Physical Therapy 2009; 39:378-387
4. Vogel S, Mars T, Keeping S et al 2012 Clinical Risk Osteopathy and Management (CROaM) project: national cross-sectional survey. BSO, London.
5. Carnes D, Mars TS, Mullinger B, Froud R, Underwood M. Adverse events and manual therapy: A systematic review. Manual Therapy 2010;15: 355-363
6. Taylor AJ, Kerry R. A systems based approach to risk assessment of the cervical spine prior to manual therapy. International Journal of Osteopathic Medicine 2010;13:85-93

Government hit from behind on whiplash injury claims

David Cameron out of touch with contemporary evidence say University of Nottingham academics!

David Cameron’s pledge to cut car whiplash claims has been challenged by University of Nottingham academics and physiotherapists Roger Kerry and Alan Taylor. Backed by leading USA researcher James Elliott, they have called into question the Government’s exposé of the whiplash injury industry in the UK.

Whilst accepting the critique of the unethical and corrupt practices within the ‘whiplash injury industry’ and a justified call for an end to so called referral fees. Kerry, Taylor and Elliott who have written extensively on neck issues and teach evidenced based practice in whiplash injury, have called into question the second layer of the broadside.  Here there is a suggestion that “all whiplash injuries are artificially contrived”, therein casting doubt on the medical legitimacy of the diagnosis at all levels. They contend that challenging the current argument is not difficult. The suggestion for instance, that ‘whiplash Injury’ is not a clinical entity is both ill informed, irresponsible and not up to date with contemporary research on the subject. They are able to draw attention to high quality objective evidence from internationally recognised MRI studies demonstrating changes in neck muscle properties in people who have suffered whiplash (e.g. Elliott et al 2010, Spine).  Furthermore, they highlight trial and experimental evidence has demonstrated that chronic whiplash associated disorder (WAD) can be reliably indentified. WAD is thus, for some a very real physical problem.

The Government’s diatribe unfortunately, calls into question the genuineness of all whiplash injury claims. This notion has, according to some, been supported further by recent media reports of a Physiotherapist winning a so called “landmark case” proving that ‘whiplash injury’ doesn’t exist (Daily Mail Jan 29^th 2012).  These reports do of course champion the proposals, but are a predictable, inaccurate spin of the facts of the quoted case, i.e. Robinson Vs Hussain, which was not technically a ’whiplash injury’ case (in fact the exact opposite of such).

For many involved in front line care delivery, the unfortunate part of this politicised rhetoric is that the proposed actions could easily lead to an irretraceable stigmatisation of the percentage patients who genuinely suffer following road traffic accidents. If wholesale changes to the industry are undertaken, there is genuine fear that evidence-based health interventions will be withdrawn for patients who have genuine, demonstrable WAD. It is important that before politically fuelled knee-jerk reforms are made, that dialogue takes place between MPs and health care practitioners such as Chartered Physiotherapists, who have been at the forefront of clinical practice and research in this area.

Government rhetoric may well be designed to galvanise public opinion and has clearly been taken up with typical emotional aplomb by tabloids such as the ‘Daily Mail’. However, it only serves to generalise and then stigmatise those patients who have genuine complaints affecting their day-to-day function. Such patients may now, in the light of this important new research, be identified by appropriate evidence based scientific tests, which the Government appear to have conveniently overlooked.

Roger Kerry (University of Nottingham, UK)

Alan J Taylor (University of Nottingham, UK)

James M Elliott (Northwestern University, USA)

References;

Elliott J, Jull G, Noteboom JT, Darnell R, Galloway G, Gibbon WW. (2006) Fatty infiltration in the cervical extensor muscles in persistent whiplash-associated disorders: a magnetic resonance imaging analysis. Spine;31(22): pp 847-55

Elliott JM, O'Leary S, Sterling M, Hendrikz J, Pedler A, Jull G. (2010) Magnetic resonance imaging findings of fatty infiltrate in the cervical flexors in chronic whiplash. Spine;35(9): pp 948-54


http://feeds.myptsd.me/are-there-implications-for-morphological-changes-in-neck-muscles-following-whiplash-injury/


http://www.nottingham.ac.uk/physiotherapy/index.aspx

https://twitter.com/#!/TaylorAlanJ