Darren A. Rivett

Can simulation replace part of clinical time? Two parallel randomised controlled trials

Medical Education 2012

Effect of premanipulative tests on vertebral artery and internal carotid artery blood flow: A pilot study

BACKGROUND Neck manipulation occasionally causes stroke after trauma to the vertebral or internal carotid artery. Premanipulativ e tests involving cervical spine rotation or extension have been recommended to detect patients at risk of neurovascular ischemia. However, the effect of these procedures on extracranial blood flow is not well established, and their validity is thus controversial. OBJECTIVE To determine the effect of premanipulative tests involving cervical spine rotation or extension on vertebral artery and internal carotid artery blood flow parameters. DESIGN Two-group experimental study. SUBJECTS Twenty subjects consisting of 16 patients treated with physiotherapy and four volunteers. METHODS Subjects were tested with a recommended premanipulative protocol by both an independent physiotherapist and an investigator. One group consisted of 10 subjects with signs or symptoms indicative of neurovascular ischemia on premanipulative testing, with 10 subjects with no signs or symptoms indicative of neurovascular ischemia on premanipulative testing comprising the second group. Hemodynamic measurements for both vertebral and both internal carotid arteries were taken by use of duplex Doppler ultrasonography with color-flow imaging with the subjects in the following positions: neutral, end-range extension, 45 degrees contralateral rotation, end-range contralateral rotation, and combined end-range contralateral rotation/extension. RESULTS The reliability of premanipulative testing was supported. Significant changes in flow velocity of the vertebral artery (and to a lesser extent of the internal carotid artery) were shown in end-range positions involving rotation and extension. No meaningful significant differences were found between the two groups. CONCLUSIONS Screening procedures that use rotation and extension may be useful tests of the adequacy of collateral circulation. A larger study is needed to determine whether subjects testing positive significantly differ from those testing negative.

Sustainable undergraduate education and professional competency

The primary purpose of Schools of Physiotherapy, and their tradition, is to develop in their students the cognitive and practical breadth required to function as competent practitioners immediately on graduation, with the capacity to continue to learn and develop. As schools within universities, they also seek to provide students with broad educational experiences, assisting them to develop generic skills such as independent learning, teamwork, responsibility towards other people, problem solving abilities and the like.

Professional responsibility in relation to cervical spine manipulation

Manipulation of the cervical spine is one of the few potentially life-threatening procedures performed by physiotherapists. Is it worth the risk? A comparison of risks versus benefits indicates that at present, the risks of cervical manipulation outweigh the benefits: manipulation has yet to be shown to be more effective for neck pain and headache than other interventions such as mobilisation, whereas the risks, although infrequent, are serious. This analysis is of particular concern because the conditions for which manipulation is indicated are benign and usually self-limiting. Because physiotherapists have legal and ethical obligations to the community to avoid foreseeable harm and provide optimum care, it may be prudent to determine who in our profession should perform cervical manipulation. That is, the profession could restrict the practice of cervical spine manipulation. Although all registered physiotherapists in Australia are entitled to perform cervical manipulation, few choose to use this intervention. Therefore, it might be feasible to encourage those practitioners who wish to use cervical manipulation to undertake formal education programs. Such a requirement could be embodied in a code of practice that discourages those without formal training from performing cervical manipulation. By taking such measures, we could ensure that our profession exercises wisdom in its monitoring and use of cervical manipulation.

Clinical prediction rules in the physiotherapy management of low back pain: A systematic review

OBJECTIVE To identify, appraise and determine the clinical readiness of diagnostic, prescriptive and prognostic Clinical Prediction Rules (CPRs) in the physiotherapy management of Low Back Pain (LBP). DATA SOURCES MEDLINE, EMBASE, CINAHL, AMED and the Cochrane Database of Systematic Reviews were searched from 1990 to January 2010 using sensitive search strategies for identifying CPR and LBP studies. Citation tracking and hand-searching of relevant journals were used as supplemental strategies. STUDY SELECTION Two independent reviewers used a two-phase selection procedure to identify studies that explicitly aimed to develop one or more CPRs involving the physiotherapy management of LBP. Diagnostic, prescriptive and prognostic studies investigating CPRs at any stage of their development, derivation, validation, or impact-analysis, were considered for inclusion using a priori criteria. 7453 unique records were screened with 23 studies composing the final included sample. DATA EXTRACTION Two reviewers independently extracted relevant data into evidence tables using a standardised instrument. DATA SYNTHESIS Identified studies were qualitatively synthesized. No attempt was made to statistically pool the results of individual studies. The 23 scientifically admissible studies described the development of 25 unique CPRs, including 15 diagnostic, 7 prescriptive and 3 prognostic rules. The majority (65%) of studies described the initial derivation of one or more CPRs. No studies investigating the impact phase of rule development were identified. CONCLUSIONS The current body of evidence does not enable confident direct clinical application of any of the identified CPRs. Further validation studies utilizing appropriate research designs and rigorous methodology are required to determine the performance and generalizability of the derived CPRs to other patient populations, clinicians and clinical settings.

International framework for examination of the cervical region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy intervention

A consensus clinical reasoning framework for best practice for the examination of the cervical spine region has been developed through an iterative consultative process with experts and manual physical therapy organisations. The framework was approved by the 22 member countries of the International Federation of Orthopaedic Manipulative Physical Therapists (October 2012). The purpose of the framework is to provide guidance to clinicians for the assessment of the cervical region for potential of Cervical Arterial Dysfunction in advance of planned management (inclusive of manual therapy and exercise interventions). The best, most recent scientific evidence is combined with international expert opinion, and is presented with the intention to be informative, but not prescriptive; and therefore as an aid to the clinicians clinical reasoning. Important underlying principles of the framework are that 1] although presentations and adverse events of Cervical Arterial Dysfunction are rare, it is a potentially serious condition and needs to be considered in musculoskeletal assessment; 2] manual therapists cannot rely on the results of one clinical test to draw conclusions as to the presence or risk of Cervical Arterial Dysfunction; and 3] a clinically reasoned understanding of the patients presentation, including a risk:benefit analysis, following an informed, planned and individualised assessment, is essential for recognition of this condition and for safe manual therapy practice in the cervical region. Clinicians should also be cognisant of jurisdictionally specific requirements and obligations, particularly related to patient informed consent, when intending to use manual therapy in the cervical region.

Risk factors and clinical features of craniocervical arterial dissection

Craniocervical arterial dissection is one of the most common causes of ischaemic stroke in young people and is occasionally associated with neck manipulation. Identification of individuals at risk will guide risk management. Early recognition of dissection in progress will expedite medical intervention. Study aims were to identify risk factors and presenting features of craniocervical arterial dissection. Medical records of patients from the Hunter region of New South Wales, Australia aged ≤ 55 years with radiographically confirmed or suspected vertebral or internal carotid artery dissection, were retrospectively compared with matched controls with stroke from some other cause. Records were inspected for details of clinical features, presenting signs and symptoms and preceding events. Records of 47 dissection patients (27 males, mean age 37.6 years) and 43 controls (22 males, mean age 42.6 years) were inspected. Thirty (64%) dissection patients but only three (7%) controls reported an episode of mild mechanical trauma, including manual therapy, to the cervical spine within the preceding three weeks. Mild mechanical trauma to the head and neck was significantly associated with craniocervical arterial dissection (OR 23.53). Cardiovascular risk factors for stroke were less evident in the dissection group (<1 factor per case) compared to the controls (>3).

Factors related to thumb pain in physiotherapists

The aim of this study was to determine whether differences exist between physiotherapists with work-related thumb pain and physiotherapists without thumb pain. Twenty-four physiotherapists with work-related thumb pain (Pain Group) and 20 physiotherapists without thumb or wrist pain (Non-pain Group), who were working at least 20 hours per week in an outpatient musculoskeletal setting, were compared on a number of attributes: generalised joint laxity, hand and thumb strength, height, weight, working environment, hand position and force applied during mobilisation, mobility at individual thumb joints, extent of osteoarthritis at the thumb and radial-sided wrist joints, and demographic data including age, gender and years of experience. All physiotherapists in the Pain Group reported their thumb pain was related to and initially caused by the performance of manual techniques, and 88% had altered their manual techniques because of pain in the thumb. There was extreme variability in hand position and force applied during mobilisation, and a slightly high prevalence of osteoarthritis (22.7%) considering the mean age of the total sample (38.6 years). Statistically significant differences between groups included increased right carpometacarpal joint laxity (6.4%, 95% CI 0.19 to 12.6), decreased right tip pinch strength (0.84 kg, 95% CI 0.01 to 1.68), and lower body mass index (2.0, 95% CI 0.11 to 3.9) for the Pain Group. Other factors were not statistically different between groups. These results indicate that work-related thumb pain affects physiotherapists ability to administer manual treatments, and suggest that decreased stability and strength of the thumb may be associated with work-related thumb pain.

Negative pre-manipulative vertebral artery testing despite complete occlusion: a case of false negativity?

The application of manipulative or high velocity thrust procedures to cervical spinal joints is associated with a very low risk of neurovascular compromise (Dabbs & Lauretti 1995; Hurwitz et al 1996; Rivett 1997; Shekelle & Coulter 1997). Although the actual incidence rate is yet to be conclusively determined, there is consensus in the literature that iatrogenic accidents of this type are rare. Despite the infrequency of these incidents, the potentially lethal or disabling outcomes have prompted professional bodies to recommend clinical pre-manipulative protocols to screen for patients at risk of stroke following neck manipulations (APA 1988; Grant 1996). Cervical spine positional tests are commonly recommended which utilize extension, rotation and/or some combination thereof (Aspinall 1989; Grant 1994). The rationale of the tests is that vertebral artery blood flow may be compromised by mechanical stresses related to these positions, particularly at the atlanto-axial segment, leading to the clinical manifestation of signs and symptoms of vertebrobasilar insufficiency (VBI) (Brown & Tatlow 1963; Grant 1994; Refshauge 1994). A patient demonstrating a possible ischaemic response to testing is deemed unsuitable for cervical manipulative treatment, whereas a negative response indicates it is appropriate to perform neck manipulation (APA 1988). However, the validity of the positional tests in detecting patients at risk of stroke is the subject of increasing controversy and research (Kunnasmaa & Thiel 1994; Refshauge 1994; Thiel et al 1994; C6t6 et al 1996;

Simulation can contribute a part of cardiorespiratory physiotherapy clinical education: Two randomized trials

Introduction Simulated learning environments (SLEs) are used worldwide in health professional education, including physiotherapy, to train certain attributes and skills. To date, no randomized controlled trial (RCT) has evaluated whether education in SLEs can partly replace time in the clinical environment for physiotherapy cardiorespiratory practice. Methods Two independent single-blind multi-institutional RCTs were conducted in parallel using a noninferiority design. Participants were volunteer physiotherapy students (RCT 1, n = 176; RCT 2, n = 173) entering acute care cardiorespiratory physiotherapy clinical placements. Two SLE models were investigated as follows: RCT 1, 1 week in SLE before 3 weeks of clinical immersion; RCT 2, 2 weeks of interspersed SLE/clinical immersion (equivalent to 1 SLE week) within the 4-week clinical placement. Students in each RCT were stratified on academic grade and randomly allocated to an SLE plus clinical immersion or clinical immersion control group. The primary outcome was competency to practice measured in 2 clinical examinations using the Assessment of Physiotherapy Practice. Secondary outcomes were student perception of experience and clinical educator and patient rating of student performance. Results There were no significant differences in student competency between the SLE and control groups in either RCT, although students in the interspersed group (RCT 2) achieved a higher score in 5 of 7 Assessment of Physiotherapy Practice standards (all P < 0.05). Students rated the SLE experience positively. Clinical educators and patients reported comparability between groups. Conclusions An SLE can replace clinical time in cardiorespiratory physiotherapy practice. Part education in the SLE satisfied clinical competency requirements, and all stakeholders were satisfied.