Alan J. Taylor

Cervical arterial dysfunction and manual therapy: A critical literature review to inform professional practice

An abundance of literature has attempted to provide insight into the association between cervical spine manual therapy and cervical artery dysfunction leading to cerebral ischaemic events. Additionally, specific guidelines have been developed to assist manual therapists in clinical decision-making. Despite this, there remains a lack of agreement within the profession on many issues. This paper presents a critical, re-examination of relevant literature with the aim of providing a contemporary, evidence-informed review of key areas regarding the neurovascular risks of cervical spine manual therapy. From a consideration of case reviews and surveys, haemodynamic principles, and blood flow studies, the authors suggest that: (1) it is currently impossible to meaningfully estimate the size of the risk of post-treatment complications; (2) existing testing procedures have limited clinical utility; and (3) a consideration of the association between pre-existing vascular risk factors, combined with a system based approach to cervical arterial haemodynamics (inclusive of the carotid system), may assist manual therapists in identifying at-risk patients.

Ankle to brachial pressure index in normal subjects and trained cyclists with exercise-induced leg pain.

PURPOSE This study compared ankle to brachial pressure indices (ABPI) before and after maximal exercise in three groups in order to investigate maximal exercise testing and ABPI as a useful procedure for the differential diagnosis of exercise-induced leg pain (EILP) in athletes. METHODS ABPI measurements were taken before and after cycle ergometer exercise to volitional exhaustion or reproduction of symptoms in three groups: 1) untrained individuals (N = 10, 3 female, 7 male; age 35 +/- 5 yr (mean +/- SD)); 2) trained cyclists (N = 10, 3 female, 7 male; age, 30 +/- 5 yr); and 3) symptomatic group of trained cyclists, complaining of EILP (N = 12, 2 female, 10 male; age, 35 +/- 9 yr). RESULTS Resting blood pressure indices were similar in all groups. ABPI were reduced (P < 0.05) in all groups after exercise. No differences between left and right legs were noted in the elite and untrained groups; however, a significant difference (P < 0.05) was noted between the nonsymptomatic (0.79 +/- 0.10) and symptomatic (0.61 +/- 0.20) legs in the subjects with EILP. Despite these group results, only three subjects in the symptomatic group met the published criteria (index of < 0.5) for endofibrosis of the external iliac artery. All positive ABPI tests were subsequently confirmed via arteriogram. CONCLUSION Maximal exercise testing combined with ABPI measurement is a simple noninvasive procedure that may be useful for the examination of EILP. The results of this study suggest that, in cases with unilateral symptoms, a between-leg ABPI difference of 0.18 (at the first minute of recovery) may be considered as a useful additional diagnostic criterion.

TRAUMATIC OCCLUSION OF THE EXTERNAL ILIAC ARTERY IN A RACING CYCLIST : A CAUSE OF ILL DEFINED LEG PAIN

Stenosis of the external iliac artery in healthy athletes, although uncommon, has been reported in competition cyclists. A case of a racing cyclist whose chronic vague leg symptoms were incorrectly attributed to L4/5 nerve root irritation is reported. This highlights the importance of clinical vascular testing when assessing ill defined leg pain. The role of trauma as a causative factor in this condition has not been previously documented.

Vascular Assessment in Musculoskeletal Examination

Vascular assessment is fast becoming an essential tool of manual therapists. We ignore the vascular system at our peril – as recent media reports have illustrated.

Arterial pathology and cervicocranial pain - differential diagnosis for manual therapists and medical practitioners

Abstract This article reviews vascular causes of head and neck pain with regard to the current available evidence. It considers the overall assessment of the patients suitability to undergo any form of manual therapy intervention ranging from simple exercise-based prescription, through to mobilisation and/or manipulative therapies. A brief review of regional anatomy combined with potential complications of system failure is presented. This is linked to an overview of the key signs for the alert practitioner to look for, together with some consideration of underlying risk factors (with regard to vascular pathology).

Cervical Spondylotic Myelopathy presenting as mechanical neck pain: A case report

Cervical Spondylotic Myelopathy (CSM) is the most common type of myelopathy in adults over 55 years of age. In the early stages symptoms may include local neck pain and stiffness that might mimic the presentation of non-specific mechanical neck pain (NSMNP). The patient was a 79 year old male, who complained of eight weeks of neck pain. He had been referred for physiotherapy by his family physician with a diagnosis of NSMNP. Initial presentation was consistent with the referral, but further assessment by the physiotherapist revealed findings suggestive of CSM. He was referred for an urgent cervical MRI scan, which revealed myelomalacic changes at C3/4 due to spondylotic changes. The patient was unsuitable for manual therapy intervention and was referred to a spinal orthopaedic surgeon who performed a posterior decompression and stabilisation at C3-C5, 2 months after the initial presentation. This case report highlights the importance of considering CSM in adults over 55 years of age presenting with NSMNP, particularly as the prevalence of both increases with age. It demonstrates the need for health professionals to carry out detailed examination where CSM may be a potential differential diagnosis. Outcomes are less favourable for patients over the age of 70, therefore an urgent surgical opinion was required for this patient. Deterioration of symptoms whilst he awaited surgery demonstrates how missed diagnosis may lead to possible long term spinal cord damage, with potential medico-legal concerns for the therapist.

When Chronic Pain Is Not “Chronic Pain”: Lessons From 3 Decades of Pain

The current move in physical therapy toward the biopsychosocial management of chronic pain has led some interpreters to call for a less hands-on approach, as awareness of central sensitization leads to specific management trends and a move away from pathoanatomical considerations. The authors of this Viewpoint suggest that no approach, no matter how vocal and evangelistic its followers, would likely be any more certain than what preceded it. This Viewpoint poses the question, why, when we (as a profession) appear (according to the new physical therapy gurus) to have been so wrong before, do we appear to believe that we are right this time? J Orthop Sports Phys Ther 2017;47(8):515-517. doi:10.2519/jospt.2017.0606.