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
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
