Roger Kerry

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.

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.

At the borders of medical reasoning: aetiological and ontological challenges of medically unexplained symptoms

Medically unexplained symptoms (MUS) remain recalcitrant to the medical profession, proving less suitable for homogenic treatment with respect to their aetiology, taxonomy and diagnosis. While the majority of existing medical research methods are designed for large scale population data and sufficiently homogenous groups, MUS are characterised by their heterogenic and complex nature. As a result, MUS seem to resist medical scrutiny in a way that other conditions do not. This paper approaches the problem of MUS from a philosophical point of view. The aim is to first consider the epistemological problem of MUS in a wider ontological and phenomenological context, particularly in relation to causation. Second, the paper links current medical practice to certain ontological assumptions. Finally, the outlines of an alternative ontology of causation are offered which place characteristic features of MUS, such as genuine complexity, context-sensitivity, holism and medical uniqueness at the centre of any causal set-up, and not only for MUS. This alternative ontology provides a framework in which to better understand complex medical conditions in relation to both their nature and their associated research activity.

Causation and evidence-based practice: an ontological review.

This paper explores the nature of causation within the framework of evidence-based practice (EBP) for health care. The aims of the paper were first to define and evaluate how causation is presently accounted for in EBP; second, to present an alternative causal account by which health care can develop in both its clinical application and its scientific research activity. The paper was premised on the idea that causation underlies medical and health care practices and impacts on the way we understand health science research and daily clinical practice. The question of what causation is should therefore be of utmost relevance for all concerned with the science, philosophy and progress of EBP. We propose that the way causation is thought of in contemporaneous health care is exposed by evidential frameworks, which categorize research methods on their epistemological strengths. It is then suggested that the current account of causation is limited in respect of both the functionality of EBP, and its inherent scientific processes. An alternative ontology of causation is provided, which has its roots in dispositionalism. Here, causes are not seen as regular events necessitating an effect, but rather phenomena that are highly complex, context-sensitive and that tend towards an effect. We see this as a better account of causation for evidence-based health care.

Content not quantity is a better measure of muscle degeneration in whiplash

Whiplash associated disorder (WAD) represents an enormous economic, social and personal burden. Five out of 10 people with WAD never fully recover and up to 25% continue to have moderate to severe pain-related disability. Unfortunately, clear and definitive reasons as to why half of individuals with WAD recover uneventfully and the other half do not, remain elusive. Identifying the factors that can reliably predict outcome holds considerable importance for not only WAD, but arguably for other acute musculoskeletal traumas. The precise pathology present in WAD has been controversial and often biased by outdated models. Fortunately, a combination of new measurement technology that illuminates pain processing, physical and social functioning and post-traumatic stress responses (and possibly markers of altered muscle size/shape/physiology) is providing a clearer picture of the multisystem pathophysiology in individuals with persistent WAD. The aim of this professional issues paper is to illuminate the clinical and research communities with regards to the growing body of knowledge for determining the trajectory of a patient with whiplash.

The use of proprioceptive neuromuscular facilitation in physiotherapy practice

Abstract Aims: The aim of this paper is to critically review the evidence base for the use of proprioceptive neuromuscular facilitation (PNF) in physiotherapy practice. Given the evolving understanding of underlying physiological concepts and research developments in the more than 50 years since Herman Kabat originated the concept, there is a need to review the current evidence base. Method: Empirical studies investigating the effectiveness of PNF for increasing range of movement and functional rehabilitation for clinical and non-clinical populations along with patterns and irradiation concepts were reviewed. Results: Although it was difficult to draw definitive conclusions due to the lack of cognate studies and varying methodological quality of papers, a number of studies did demonstrate encouraging results for the use of PNF, particularly with regard to increasing range of movement. Conclusions: Further research is needed to explore individual components of PNF therapeutic approaches and their wider application in key clinical populations such as stroke with standardized outcome measures appropriate to clinical practice. Secondly there is need for the development of new paradigms to fully consider the underlying physiological concepts explaining the effectiveness of PNF.

Philosophy of science and physiotherapy: An insight into practice

This article presents an overview of the philosophy of science and applies such philosophical theory to clinical practice within physiotherapy. A brief history of science is followed by the theories of the four most commonly acknowledged philosophers, introduced in the context of examples from clinical practice. By providing direct links to practical examples, it demonstrates the possibilities of relating the logical basis of this field of study to the clinical setting. The relevance to physiotherapy is that, by relating this theory, clinicians can better understand and analyse the fundamental logic behind their practice. The insight this provides can benefit professional development in several ways. For the clinician, it permits more comprehensive and coherent reasoning and helps to relate evidence with respect to individual patients. On a larger scale, it encourages reflective discussion between peers around the virtues of alternative treatment approaches. Thus, this topic has the potential to guide clinical practice toward being more scientific and may help raise the credibility of the profession as a whole.

Pre-manipulative Procedures for the Cervical Spine New guidelines and a time for dialectics: Knowledge, risks, evidence and consent

Summary The Australian Physiotherapy Association has recently released updated guidelines for pre-manipulative procedures for the cervical spine ( Magarey et al , 2000 ). These guidelines replace the protocol published in 1988 (APA, 1988), upon which much manipulative practice in Britain has been based. Therefore the recognition of the new protocol is of paramount importance in our manipulative community. Following the release of these guidelines, the Australian Journal of Physiotherapy published a discussion forum inviting comment from learned and interested individuals in the field of manipulative therapy ( AJP , 2001 ). This discussion forum is perhaps of greater importance than the release of the guidelines itself. The forum highlights some of those great areas of debate in our profession that seemingly move further away from a communal consensus of opinion. These are the issues of established public knowledge base, risk of practice, evidence-based practice, and informed consent. The area of cervical manipulation is perhaps the most sensitive and logical area to discuss these issues, and the journals forum certainly proved that consensus of opinion on any of these areas is a goal yet to be within sight. This article discusses each of these issues in turn with reference to points raised by the forum on pre-manipulative testing of the cervical spine.

The immediate effect of atlanto-axial high velocity thrust techniques on blood flow in the vertebral artery: A randomized controlled trial

BACKGROUND High velocity thrust (HVT) cervical techniques have been associated with serious vertebral artery (VA) trauma. Despite numerous studies, the nature of this association is uncertain. Previous studies have failed to demonstrate haemodynamic effects on the VA in simulated pre-thrust positions. No study has investigated haemodynamic affects during or immediately following HVT, nor sufficiently controlled for the influence of the thrust. OBJECTIVES To investigate the immediate effects of HVT of the atlanto-axial joint upon haemodynamics in the sub-occipital portion of the vertebral artery (VA3). DESIGN Randomized Controlled Trial. METHOD Twenty-three healthy participants (14 women, 9 men; mean age 40, range 27-69 years of age) were randomly assigned to two groups: an intervention group (MANIP, n = 11) received HVT to the atlanto-axial segment whilst a control group (CG, n = 12) was held in the pre-manipulative hold position. Colour-flow Doppler ultrasound was used to measure VA3 haemodynamics. Primary outcome measures were peak systolic (PSV) and end diastolic velocities (EDV) of three cardiac cycles measured at neutral (N1), pre-HVT (PreMH), post-HVT (PostMH), post-HVT-neutral (N2) positions. RESULTS Test-retest reliability for the Doppler measures demonstrated intra-class correlation coefficient (ICC) of 0.99 (95% CI 0.98-1.0) for PSV and 0.91 (95% CI 0.84-0.96) for EDV. Visually, EDV were lower in the MANIP group than in the CONTROL group across the four measurements. However, there were no significantly different changes (at p ≤ 0.01) between the MANIP and CONTROL groups for any measurement variable. CONCLUSIONS HVT to the atlanto-axial joint segment does not affect the haemodynamics of the sub-occipital portion of the vertebral artery during or immediately following HVT in healthy subjects.

Time, space and form: Necessary for causation in health, disease and intervention?

Sir Austin Bradford Hill’s ‘aspects of causation’ represent some of the most influential thoughts on the subject of proximate causation in health and disease. Hill compiled a list of features that, when present and known, indicate an increasing likelihood that exposure to a factor causes—or contributes to the causation of—a disease. The items of Hill’s list were not labelled ‘criteria’, as this would have inferred every item being necessary for causation. Hence, criteria that are necessary for causation in health, disease and intervention processes, whether known, knowable, or not, remain undetermined and deserve exploration. To move beyond this position, this paper aims to explore factors that are necessary in the constitution of causative relationships between health, disease processes, and intervention. To this end, disease is viewed as a causative pathway through the often overlapping stages of aetiology, pathology and patho-physiology. Intervention is viewed as a second, independent causative pathway, capable of causing changes in health for benefit or harm. For the natural course of a disease pathway to change, we argue that intervention must not only occupy the same time and space, but must also share a common form; the point at which the two pathways converge and interact. This improved conceptualisation may be used to facilitate the interpretation of clinical observations and inform future research, particularly enabling predictions of the mechanistic relationship between health, disease and intervention.