Forget models, mantras and gurus ... Listen to the patient

The current debate in Physiotherapy about the use and misuse of evidence based medicine (EBM) was well and truly polarised by Roger Kerry's recent Evidence-Based Physiotherapy: A Crisis in Movement.

In a brilliant no holds barred polemic, the author called made a plea for sanity in a World gone mad. It got me to thinking. I've long been an advocate of big picture thinking, and puzzled for many an hour and longer about why we think the way we do. Why for instance, physiotherapists got fixated with the vertebral artery, back in the day when spinal manipulation was all the rage. It slowly became apparent that there was more to cervical vascularity than just the vertebral arteries. Hence the development of a system based approach to the issue which focused on movement (not JUST manipulation), all of the vascular system (not JUST the vertebral artery) and all of the potential pathologies (not JUST dissection).

The result was a risk assessment framework which offers sound guidance and direction for those offering any movement based interventions (including assessment) for patients with head and neck pain. The IFOMPT document is not a guideline, rather a framework for THINKING, for clinical reasoning, and directs clinicians to make decisions based on the big picture. It exhorts clinicians to familiarise themselves with cranial nerve testing, surprisingly, (and perhaps alarmingly) not part of the skill set of many PT's, and to consider blood pressure as an additional risk assessment tool. None of this was rocket science BUT, it was perhaps an example of restricted thinking, dominated by the 'experts' of the time.

The new 'experts' of our time are the social media commentators, the 'institutes' the 'organisations' who shape our opinion with their interpretation of EBM. Many seem to shout loudly (and with significant bias) from the roof tops about what we should or shouldn't do. It is a fascinating dynamic, which I have observed from both within and afar. When internationally respected pain expert Mick Thacker wrote a guest editorial recently for Pain and Rehabilitation - the Journal of Physiotherapy Pain Association, he upset the apple cart. He challenged the use of 'mantras' and singular thinking with another brilliantly written piece entitled 'is pain in the brain?'  His commententary, that he was surprised that such views about pain were "…so widely accepted by physiotherapists considering our backgrounds", caused outrage in some quarters and he was was vilified on social media by disciples of the pain/biopsychosocial model. They argued their case with such tactical vigour, you would have to conclude they could not be wrong …. unless of course, you were thinking.

It is perhaps the absolute certainty of some, that I find most fascinating and perhaps a little dangerous.

It is time, as my colleague so rightly said, that we all begin to think for ourselves.

Image via

John Eisenschenk

https://www.flickr.com/photos/johne777/9388708662


There's no doubt that the biopsychosocial model has much to offer and only a fool would deny its role and value. But should you throw yourself at its alter? The biomedical model has many limitations, that are well recognised.




But when a patient presents with a worsening scenario, it is worth remembering that not everything is a 'flare up' and just as 'hurt does not always equal harm' ... SORRY but, sometimes it does!

Similarly, whilst modern science suggests most patients with LBP for instance don't require scans or X rays … some do.

It remains our job to be able to recognise those cases and manage the others with whatever skills we have left at our disposal. Otherwise, a sheep like adherence to one particular school of thought may prove to be our undoing. We need to know examination skills, we need to know pathologies … we need to know when scans or triage are appropriate, we need to know the limitations of our own thinking, all these things matter.

I decided to illustrate my point with a cute story ... which nicely illustrates the shortcomings of both 'models' and how we truly have to listen to our patients and put aside our preconceptions.

Mr Xrayspecs (a 52 year old builder and hobby cyclist) walked into my clinic recently, referred from another Physiotherapy colleague. He presented with a description of chronic lower back pain and non specific left leg pain.

I introduced myself and asked him why he'd come to see me.

"Well, I have this pain you see, and I think it's getting worse, so my physio sent me to see you … seems to think you might be able to help" he said, somewhat doubtfully.

"Tell more about it " I asked.

"Well it all started 34 years ago". "34 years", I mirrored and sat back in the chair ready for the long haul.

"They've tried everything" he went on. First, when my leg started aching (aged 18), they said I had a trapped nerve 'sciatica' they called it. They said I'd got an asymmetry. They gave me lots of treatment, you know manipulations and stuff but nothing worked. Then I went to the osteopath and he put all my joints back in … but that didn't work either."

It was a familiar story ... one I've heard (probably like you) many times before.

He went on "I just tried to ignore it and carry on riding my bike, but the pain came on every time and my leg felt weak."

Oh, so you felt it whilst you were cycling did you?" I interjected. "YES", he reiterated with some agitation. "Tell me more", I asked, ... "They said I must be trapping a nerve or something, probably because I was bending forward, on the bike". "Oh" I said, thoughtfully. "Then they sent me for a scan, but nothing showed up".

https://pixabay.com/en/bicycle-old-bike-cycle-retro-ride-497329/ 

He continued, "I was getting really fed up I can tell you, and about 3 years had gone by". "OK, I can understand that" I said compassionately. "Then what happened" I asked. "Well, thats when they said it might all be in my head" he said (his words). "They sent me to a pain clinic, gave me some injections and told me I should self manage it, but I knew something was wrong". "Oh" I said, brilliantly … pausing for dramatic effect.

"What did YOU think was wrong" I asked. "Well I didn't know what exactly ... but I knew my leg wasn't right, it felt weird, weak, strange, but when I started to say that, I think they thought I was a bit mad, so I backed off a bit". "Oh" I said again, somewhat repetitively, but he carried on regardless.

"I've been to every specialist you can name, orthopaedics, sport, pain, physios, osteopaths, chiropractors, masseurs, you name it, I've been there". "And" I said, probing hopefully. "Well its just getting worse and now I've got back ache too" he continued. "They sent me for more scans recently and I've got wear and tear and disc degeneration now ... and they said that must have been the problem all along".

"So now I'm labelled with chronic pain and I'm having CBT and all that psychological pain education stuff". "Oh", I said hopefully. "Yeah but that's a waste of time, just like the rest of it was … pacing whats that gonna do? Mindfulness? I'm a bloody builder … I'm getting worse, not better and NOBODY LISTENS", he said, pausing for effect.

"What do you mean" I said. "NOBODY LISTENS" he said again, somewhat menacingly.

Image via - http://strawberry-lollipops.deviantart.com/art/Listen-to-me-102802029

I leaned forward, listening intently with wide eyes. "Look when it all began, it always came on when I was exercising, and it still does, like when I ride my bike, or push a wheelbarrow on site or go up the steps to the roof … I might have back ache now but I didn't before and my leg still feels like it's got no blood flowing into it. To be fair I've been saying that for 34 years but everyone glazes over … Its like they only want to fit you into their bag, their particular pet theory".

At that point I laughed out loud. "It's not funny" he said. "No, no" I apologised, "I'm not laughing at YOU, I'm laughing at me ... US!" I stuttered.

"What do you mean" he demanded. 'Well" I began, " I think my colleague may have sent you to see me because he thinks I may have a pet theory too" … It went quiet … I took up the cudgels.

"When you said that your leg felt like it had no blood going to it, did anybody test for that." I asked. "No" he said, "they just kept talking about nerves or discs initially, then chronic pain and CBT and how 'pain is in the brain' and stuff, like I explained." he said.

I asked a few more probing questions about the nature of his pain and asked him to lay on the couch.

I took his lower limb pulses - Normal.
I took his brachial blood pressure - Normal.
I took his ankle blood pressures - Normal.

I asked if he was still riding his bicycle and if his pain still came on with cycling. "Yes" he said, "as regular as clockwork … as soon as I get to 145 bpm on the heart rate monitor." "Oh" I said. "Can we ask you to exercise to that level I asked'?

"You can bloody well ask me to do what you like if we can get to the bottom of this bugger" he said cracking a smile for the first time. I explained that we may find nothing at all, and asked him again if wished to continue with a simple exercise test. He was already climbing eagerly onto the exercise bike and adjusting his pulse monitor belt.

The exercise test quickly reproduced his leg pain as predicted, as soon as he reached around the 145 bpm mark. I pushed him a little further… 165 bpm "Yes", he said with some satisfaction. "Now my leg feels funny, weak, like theres no blood going to it".

He jumped off the bike and we lay him on the couch … we replaced the left and right BP monitors onto the ankles and inflated them, they ran simultaneously.

At minute 1 (post exercise) the systolic brachial BP was 185 mmhg

At minute 1 the right ankle systolic BP was 160 mmhg. The left recorded nothing (I waited … I'd seen this before) ... the BP can be lower than the machine can record.

At minute 2 the systolic brachial was 180

At minute 2 the RIGHT ankle BP = 155

At minute 2 the LEFT ankle BP = 70 mmhg 

Post exercise ankle brachial pressure index (ABPI) was calculated as 70/180 = 0.39

The published cut off point for post exercise ABPI is currently 0.6 (Peach et al, 2012)


I'd turned the BP monitors away from his gaze … He was anxious to know the result.

I explained that he would no longer need to continue with the mindfulness and CBT.

He was referred to the vascular surgeon with a full outline of the consultation and test results.

4 weeks later (after the tests had been repeated the vascular clinic) magnetic resonance imaging of the arteries revealed a significant flow reduction to the left lower limb in the region of the external iliac artery.

The patient underwent a 5 hour vascular surgery (longer than expected due to the complex intra-operative findings) involving endarterectomy and shortening of a 'significantly tortuous artery'.

He made a full recovery and 6 months post surgery reports NO LEG PAIN under any conditions, including exercise. He still gets intermittent low back pain, which he considers to be "normal".

His post exercise ABPI measures have returned to within normal limits (> 0.6)

He has returned to full function work/cycling/running/skiing with NO LEG SYMPTOMS.

For various reasons linked to clinical reasoning and therapist/physician beliefs ... it took 34 years to get to the bottom of this case.

For an analysis of quite how that could be ... try a stab at the 5 Whys of ROOT CAUSE ANALYSIS 

What do we all have to learn from this case.

1. Listen to the patient

2. There are limitations of BIOMEDICAL reasoning

3. There are limitations of BIOPSYCHOSOCIAL reasoning

4. NEVER have blind faith for 1 paradigm

5. Know your pathology

6. KEEP LISTENING TO THE PATIENT

7. N=1 (it REALLY does)

8. It's OK to be discombobulated ... Just say "Oh"

 ... and just for the record, there is NEVER absolute certainty.

Image via Steven Shorrock https://www.flickr.com/photos/highersights/6231641551

Author: Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist and University Assistant Professor ... The views contained in this blog are his own and are not linked to any organisation or institution. Like Bukowski, he 'writes to stay sane'.

You'll find him mostly on Twitter https://twitter.com/TaylorAlanJ
... that is until, he finally deletes his account, or is 'evidence based blogged' to oblivion. 

Understanding cervical arterial dysfunction (CAD) for clinicians

 

The publication of the succinctly titled;

‘International framework for examination of the cervical region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy intervention’ (Rushton, et al 2013)

... has highlighted the need for manual therapy clinicians to be cognisant with cervical arterial dysfunction (CAD). 

BUT what is that? … and what does it mean to clinicians?

Let us start ... by dealing with what it is NOT

Dissection of an artery

1. Cervical arterial dysfunction is NOT cervical arterial dissection! That may seem obvious to some, but both acronyms are now in common usage and therefore some confusion may arise. The term dissection is specific to dissection events (see image) and therefore narrow. Cervical arterial dysfunction is a broader term which is all-encompassing of a range of pathologies which may affect the cervico-cranial vasculature. 
2. CAD is NOT vertebro-basilar insufficiency (VBI). However, it does incorporate it - as one of the component parts of a wider system based approach to thinking about haemodynamics and ischaemia
3. Above all, CAD is NOT (in isolation) dissection of the vertebral artery. That would simply be a continuation of the narrow thought process which lead us to believe that a single test i.e. the vertebral artery test, could somehow allow us to decide whether cervical manipulation was ‘safe’ or not! That outdated concept has thankfully been de-bunked once and for all, as we move closer to science based practice.

So what is cervical arterial dysfunction then…?

CAD is a consideration of ALL of the potential arterial dysfunctions, which may present to, or ensue from a manual therapy intervention.

CAD is simply a way of thinking about an age old problem in a different way, and more importantly asking ourselves different questions about this familiar problem – linked to RISK and cervical spine management. The emphasis has moved firmly away from just ‘manipulation’, into a consideration of movement per se. This clearly widens the thinking into a consideration of ASSESSMENT (which incorporates movement) as well as intervention, which may incorporate ANY form of manual therapy or exercise prescription. This is then combined with a consideration of ALL of the potential structures and vascular 'dysfunctions'. Thinking is no longer constrained by one structure or pathology.

So why the shift from VBI and vertebral artery dissection …?

Well first of all, there is a lot more to the cervical vasculature than the vertebro-basilar system and there is a lot more to the range of pathologies than just dissection. Dissection or damage to the intimal wall of a vessel is a commonly cited vascular ‘injury’ thought to be associated with cervical spine manipulation in particular. However, an understanding of the basic science of haemodynamics allows us to incorporate many more conditions and pathologies into the paradigm. 

There are a range of reasons why blood vessels may be compromised in the cervico-cranial region, from pre-existing underlying anatomical anomalies, vasospasm, atherosclerotic disease, through to arteritis (i.e. temporal). All of these may lead in different ways, to potential ischaemia which may manifest and a variety of ways, ranging from PAIN, through to blindness, stroke or at worst death.

 Some direction for clinicians:

• Develop an understanding that there is more to cervical spine risk assessment than a consideration of ‘VBI’ or dissection of the vertebral artery.
• Consider a ‘systems based’ approach, incorporating the whole cervical vascular system, including the carotid vasculature (and branches) and the whole range of potential pathologies (NOT just dissection).
• Develop awareness, that whilst commonly cited vascular risk factors have not been shown to be associated with dissection pathologies, they are strongly correlated with atherosclerosis, hypertension and stroke … This is ‘system based thinking’.
• Develop increased awareness that neck pain and headache may be the early signs of pre-existing vascular dysfunction.
• Develop an index of suspicion for cervico-cranial vascular pathology, particularly in cases of acute trauma or non-resolving/worsening conditions.
• Enhance subjective/objective examination by including vascular risk factors such as hypertension, and procedures such as blood pressure, cranial nerve testing and eye examination.
• Consider carefully the ORDER of your examination in the presence of potential vascular ‘red flags’.
• Expand manual therapy teaching and practice to include haemodynamic principals and their relationship to movement, handling, anatomy and biomechanics.

Despite all this … when all is said and done, the 64m dollar question still seems to be … Should clinicians perform a ‘vertebral artery test’?

Answer … there is little to support it's use as a stand alone test. Its sensitivity and specificity are very poor AND its clinical utility is of little value. It has been argued that it should be retained from a 'medico-legal' perspective, but that contention would most likely be destroyed by any half competent barrister.

Note - that cranial nerve and blood pressure testing are additional objective measures to incorporate into the physical examination. Both feature prominently in the IFOMPT framework.

See:
Cranial nerve testing

Blood pressure testing

 

For a more detailed description of this paradigm change see:

A ‘system based’ approach to risk assessment of the cervical spine prior to manual therapy (Taylor & Kerry 2010) http://www.sciencedirect.com/science/article/pii/S1746068910000532

‘International framework for examination of the cervical region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy intervention’ (Rushton, et al 2013)

http://www.sciencedirect.com/science/article/pii/S1356689X13001926

Follow on Alan J Taylor on Twitter 

Haemodynamics - A 'system based approach'

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 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