The art of ‘naysaying’ …evidence based practice and whiplash associated disorder

So first of all, what is a naysayer?

Well, the Merriam-Webster gives the following definition – “a person who says something will not work or is not possible: a person who denies, refuses, or opposes something”

The Urban Dictionary definition is somewhat lengthier and perhaps more revealing:

“One who frequently engages in excessive complaining, negative banter and/or a genuinely poor and downbeat attitude.”

They continue … “Naysayers are distinguished by their tendency to consistently view the glass half empty, make frequent one-way trips to negative town, and constantly emphasize the worst of a situation. They have the keen ability to spread their pessimistic attitude to a group of unsuspecting bystanders and encourage others to employ their mind-set.” 

From a behavioural perspective they suggest that “Naysayers … will stop at nothing to bring a general sense of negativity to any situation.” 

 

BUT … What has this all got to do with Physiotherapy and evidence based practice?

 

Because it is EASY to be a naysayer in the tiny World of evidence based medicine (EBM) or practice (EBP). We seem to be beset by a veritable queue of them, some aspiring desperately to be the next EdzardErnst (he made a career out of it … and still does!) within their own ‘specialist’ domain. 

 

Physiotherapy (PT) has not escaped this trend. There is an increasing army of bloggers (he said from his blog … such irony!) and Twitterati, who now peddle their view of the World. They utilise the latest evidence, to back up their statements and often negative rants about WHAT DOESN’T work in PT (Yawn! If you haven't seen one, don't go looking for one ... you could end up writing a blog!). 

They pre-empt criticism, by cleverly suggesting that anyone who disagrees  with their interpretation of the the evidence, is either ‘unscientific’, a ‘fool’ or perhaps a ‘curmudgeon’, thereby discouraging discourse or opposing views from the outset.

…and so what?  I hear you ask!

PT has come a long way in the last decade or two, in terms of its use of the evidence base, to drive treatment interventions and mould out-dated thinking and practice. As each day goes by we find more and more studies, which guide the way we treat and rehabilitate our cases. 

Of course, it can be very puzzling and even soul destroying for clinicians to find that a mode of treatment which they believed was ‘effective’, is suddenly found by the latest study to have little or ‘no effect’ ...BUT that's life, it makes us stronger!

A good example is the recent publication in the Lancet, which suggested in its ‘Interpretation’ section … “We have shown that simple advice is equally as effective as a more intense and comprehensive physiotherapy exercise programme.”

 

This type of conclusion ... naturally comes as a body blow to clinicians, many of whom have an inherent faith in the belief that their interventions are doing good. 

 

So just when you were feeling a little vulnerable ... ENTER THE NAYSAYER! … Usually a confident and bold academic type, who with all the guile of Jeremy Clarkson in a dog naming competition

...explains gleefully in a detailed blog, that, ‘actually folks you got it all wrong’ ... which of course he/she knew all along … and which is now ‘evidenced’ by the latest trial!

Brilliantly done and incredibly EASY … BUT WHAT IS THE POINT?

Answer … There isn’t one!

… Though they WILL say, they are disseminating information … updating us all on the latest evidence. 

Errr maybe … OR it could be argued, gleefully exercising blatant ‘told you so’ promotion of their own Worldview. 

Naysayers seldom offer a pragmatic alternative ...

Academics have the luxury of being able to access, read and analyse the latest research and some do that brilliantly, as do many clinicians. As a result there is a plethora of blogs, which are designed to be genuinely helpful to clinicians and academics alike, and give thoughtful interpretations of contemporary evidence, which can be translated into practice. The sportsphysio is one excellent example, rogerkerry.wordpress is another.

Thankfully, as the Urban Dictionary helpfully suggests, naysayers are, “Not to be confused with non-naysayers … who fight against the negativity brought forth by naysayers, make the best of a situation and are not afraid to call out a naysayer on the spot.”

My personal advice to busy clinicians is to seek out the pragmatic NON-NAYSAYERS (like those mentioned above and here). Those who have the ability to construct rather than deconstruct their own profession, whilst at the same time, embracing the concepts of contemporary science and evidence based clinical practice. 

Change is required, but not via the medium of lofty negativity.

On the subject of whiplash injury

This is NOT a trivial subject … The emerging science is welcome, it is clear that PT’s will need to look carefully at current practice in the light of contemporary studies relating to Whiplash Associated Disorder. 

Prof Michelle Sterling herself, suggested a PT role in assessment, sub-grouping, early recognition of PTSD and triage (for early cognitive behavioural therapy) may well be sequelae of the groups latest findings. 

Using Michaleff et al’s study as an example, DON’T FORGET ... it only looked at one particular ‘pragmatic exercise programme’ ... devised by 'experts' YES, but was it the right type of rehab, applied at the right time? 

In other words, in the same way that the emerging research has guided our thinking on best practice in ACL rehab for example, it may well guide us further in the field of WAD.

DO NOTE (because the naysayers may have missed it ...) the final paragraph in another Lancet Article relating to WAD and exercise… 

 “… These findings should NOT be interpreted as encouragement to abandon exercise therapy in these patients: ... the question is HOW & WHEN to exercise people with chronic whiplash-associated disorders.” (upper case, for non-naysayer emphasis) 

Academics might dwell for a moment on this statement from Nijs and Hickman 2014 ... 

"Physiotherapy curricula are only starting to integrate cognitive behavioural therapy as part of pain management modules ... Future physiotherapists might have the necessary attitudes, beliefs, and skills to apply specific cognitive behavioural therapy rules during exercise therapy for chronic pain patients, including those with whiplash-associated disorders."

FINALLY clinicians, ask yourself honestly … (with or without CBT) when was the last time you REALLY applied resistance to cervical spine musculature during neck rehabilitation?  ...and more importantly, would it make any difference to outcomes?

The jury, on those particular questions will remain out for some time.  

REMEMBER pendulums swing! 

For a guide on useful BLOGS and 'Physio Twitterati' ... Here is the helpful physiotalk BLOG

- BEWARE THE NAYSAYERS -

http://funnyasduck.net/

This article was written by a curmudgeonly, argumentative NON-NAYSAYER, entirely for the purposes of pleasure and self promotion (..ha, ha!). 

Any association of this article with any particular blog ... or any person living or dead, is entirely constructed via the imagination of the reader.

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

Geary K, Green BS, Delahunt E (2014). Effects of Neck Strength Training on Isometric Neck Strength in Rugby Union Players. Clin J Sport Med. Feb 24. PMID: 24561636  

Michaleff ZA, Maher CG, Lin CW, Rebbeck T, Jull G, Latimer J, Connelly L, & Sterling M (2014). Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial. Lancet PMID: 24703832

Nijs J, Ickmans K.Lancet (2014). Chronic whiplash-associated disorders: to exercise or not?  Lancet PMID: 24703833  

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'