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Vascular profiling: Should manual therapists take blood pressure?

DOI:10.1016/j.math.2012.08.001
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Alan John Taylor at University of Nottingham
Alan John Taylor
Roger Kerry at University of Nottingham
Roger Kerry
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Abstract

Risk assessment of the cervical spine prior to manual therapy interventions is currently a contentious topic, highlighted by recent suggestions in the medical press (http://www.bmj.com/content/344/bmj.e3679), that manipulative therapy should be abandoned because of the perceived risk. This paper addresses the issue of manual therapists using blood pressure measurement as an aid to clinical reasoning and decision making. The authors' use a case series of three neuromusculoskeletal presentations, which support the contention that blood pressure recording can prove to be an appropriate objective test for assessment prior to manual therapy interventions. Furthermore, it is suggested that blood pressure testing may provide direction for risk assessment and/or the management of patients across all populations and age groups as part of a holistic 'vascular profiling' approach to clinical reasoning and decision making.
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Professional issue
Vascular profiling: Should manual therapists take blood pressure?
Alan J. Taylor
*
, Roger Kerry
University of Nottingham, Division of Physiotherapy, Clinical Sciences Building, City Hospital, Hucknall Road, Nottingham NG5 1PB, UK
article info
Article history:
Received 12 July 2012
Received in revised form
3 August 2012
Accepted 5 August 2012
Keywords:
Cervical
Manual therapy
Vascular
Risk
abstract
Risk assessment of the cervical spine prior to manual therapy interventions is currently a contentious
topic, highlighted by recent suggestions in the medical press (http://www.bmj.com/content/344/bmj.
e3679), that manipulative therapy should be abandoned because of the perceived risk. This paper
addresses the issue of manual therapists using blood pressure measurement as an aid to clinical
reasoning and decision making.
The authors’use a case series of three neuromusculoskeletal presentations, which support the
contention that blood pressure recording can prove to be an appropriate objective test for assessment
prior to manual therapy interventions. Furthermore, it is suggested that blood pressure testing may
provide direction for risk assessment and/or the management of patients across all populations and age
groups as part of a holistic ’vascular profiling’approach to clinical reasoning and decision making.
Ó2012 Elsevier Ltd. All rights reserved.
1. Introduction and background
Hypertension is a recognised risk factor in both stroke and
cardiovascular disease and it has been suggested in some studies
that up to 30% of people may be entirely unaware of this so called
‘silent killer’(Stroke Association UK, 2011). This paper addresses
the issue of manual therapists measuring blood pressure (BP) as an
aid to clinical reasoning, risk assessment and ‘vascular profiling’.It
incorporates three relevant case studies.
With the United States firmly at the forefront of the obesity
epidemic (Sturm, 2007) the American Physical Therapy Association
produced a Guide to Physical Therapist Practice (2001) which made
the recommendation that patient examination should begin with
a history and systems review which includes “anatomical and
physiological status of the cardiovascular/pulmonary system
(emphasis added), integumentary, musculoskeletal and neuromus-
cular systems. .“. The guidance went on to say, “Heart rate and BP
are measured to assess aerobic function and circulation, these
measures can assist the physical therapist in identifying cardiovas-
cular or pulmonary problems that might affect prognosis and inter-
vention or require referral to another practitioner.”In an attempt to
assess compliance with these guidelines, Frese et al. (2002) surveyed
597 physical therapy clinicians in two participating universities and
found that 43% of respondents reported “never measuring BP”, with
only 4.4% suggesting that they “always”measure BP. The most
frequently chosen responsefor such decisions was “not important for
my patient population”. This raised the question of whether practi-
tioners were conversant with the evidence base relating to the
increasing prevalence of obesity related hypertension in children for
example (Feber and Ahmed, 2010). Alternatively, it questioned
whether they were aware of the relevance of hypertension to their
clinical reasoningwithin the neuromusculoskeletal (NMS) paradigm
and their patient population.
Stroke Association statistics suggest that an estimated 150,000
people have a stroke in the UK eachyear, with stroke accounting for
around 53,000 deaths each year (Stroke Association UK, 2011).
Furthermore, ischaemic heart disease and cerebrovascular disease
comprise two (together with cancer) of the three most common
causes of death in England and Wales. The inaugural signs of stroke
linked to cervical arterial dissection are commonly reported as neck
pain and head ache in the early stages (Arnold et al., 2011). These
are precisely the symptoms for which patients might seek, or are
referred to manual therapists. Adverse incidents related to manual
therapies have been well documented (Ernst, 2010) and most
commonly result in transient ischaemic events or stroke and less
commonly death. However, manual therapy clinical reasoning has
commonly focused on the vertebral artery and dissection in
particular (Thomas et al., 2011). This serves to constrain thought
and does not align with the wider medical literature.
Risk assessment of the cervical spine prior to manual therapy
interventions is currently a contentious topic, highlighted by recent
suggestions by Wand et al. (2012), that manipulative therapy
should be abandoned because of the perceived risk. The emergence
in the UK of ‘Advanced Practitioner’roles within Physiotherapy has
brought about an increasing awareness of the responsibility of such
*Corresponding author. Tel.: þ44 (0) 115 8231805; fax: þ44 (0) 115 9673005.
E-mail address: alan.taylor@nottingham.ac.uk (A.J. Taylor).
Contents lists available at SciVerse ScienceDirect
Manual Therapy
journal homepage: www.elsevier.com/math
1356-689X/$ esee front matter Ó2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.math.2012.08.001
Manual Therapy 18 (2013) 351e353
first line practitioners as key decision makers in health care. The
Health Professions Council (HPC), UK Standards of proficiency 2b.4
states that registrant physiotherapists should “be able to conduct
appropriate diagnostic or monitoring procedures, treatment,
therapy or other actions safely and skilfully”(HPC standards of
Proficiency, 2007). The attainment of this standard clearly
requires sound clinical reasoning skills combined with an intimate
knowledge of vascular pattern recognition. This point is highlighted
in the new ‘International Federation of Orthopaedic Manipulative
Physical Therapists’standard for screening of the cervical spine
(Carlesso et al., 2012)
Manual therapies for the cervico-thoracic spine incorporate
a range of passive movement techniques ranging from soft tissue
stretching techniques through to joint mobilisation and manipu-
lation. Randomised controlled trials and systematic reviews have
shown that manual therapy techniques can benefitneckpain
(Gross et al., 2004,2010). From a risk perspective, much attention
has traditionally been given to the vertebral artery (VA) and
vertebral artery testing (Schi evink et al., 1993) despite the fact that
internal carotid artery (ICA) dissections are reported to occur 3e5
times more frequently than VA dissections. Epidemiological
studies suggest that the reported incidence for ICA dissection is
2.6e2.9 per 100,000 (Schievink et al., 1993), whilst for the VA it is
1e1.5 per 100,000 (Schievink, 2001). Furthermore, recent pub-
lished literature (Taylor and Kerry, 2010) has suggested that
asystems based approach should be used, incorporating knowl-
edge of the potential failings of the circulatory system, which may
reveal adverse arterial events. Such an approach incorporates
consideration of the carotid and vertebrobasilar vascularity as
a whole and encourages a consideration of the ‘vascular profile’of
the patient.
When considering the cranioecervicoethoracic complex, there
are a number of scenarios which may present to manual therapists
which require consideration of the vascular system. This paper will
cover a detailed exploration of three cases, including the use of
blood pressure measurement as recommended in a recent follow-
up paper by Frese et al (2011) entitled ‘blood pressure guidelines for
physical therapists’.
2. Case study 1
A 56 year old female allied health professional attended
a physiotherapy department following a road traffic accident three
weeks earlier. She complained of on-going cervical, bi-lateral tra-
pezious/scapular pain (4e6/10 visual analogue score) and a feeling
of anxiety (she described herself as a “ticking time bomb waiting to
go off”). Observation revealed muscle spasm with torticollis (right
side flexion/left rotation) and a prominent pulsatile left carotid
artery; she appeared to have a facial asymmetry and had reported
difficulty swallowing and occasional gagging when eating. Based
on the subjective history which included cardio-vascular risk
factors (hypertension, hyperlipidaemia, family history of cardio-
vascular disease) and the observed findings, initial examination
involved BP measurement (in the physiotherapy clinic.) BP was
recorded at systolic 210 and diastolic 130 (210/130); this was
repeated on the same arm and on the opposite arm. The lowest
recorded BP over five assessments was 206/122. The patient was
referred to accident and emergency where a carotid ultra-sound
scan revealed an “abnormally tortuous”left carotid artery with
mild vessel wall thickening (atherosclerosis) but no evidence of
arterial dissection or aneurysm. She was medically treated by her
physician for her known hypertension and referred back to phys-
iotherapy, where she was treated with low risk techniques (i.e.
avoiding techniques which may mechanically compromise the
vascular system) and made a full recovery.
3. Case study 2
A 32 year old male professional musician (guitarist and singer)
had been treated with manual therapy (Chiropractic) for his
thoracic/chest pain and ‘low energy levels’with little or no
improvement over three months. He initially presented com-
plaining of a one year history of mild (2e3/10) thoracic and anterior
chest pain with occasional left arm symptoms (paraesthesia). He
had none of the classical vascular risk factors but had suffered
a brain aneurysm aged 11 years which required emergency surgery
from which he made a full recovery. More recently the initial
symptoms had been associated with increasing left arm paraes-
thesia/discomfort, fatigue, episodes of near syncope (feeling faint)
and breathlessness when playing Frisbee (i.e. exertion). He re-
visited his general practitioner (GP) at the behest of his Chiro-
practor who had noted latterly that his BP readings were abnor-
mally low. Initial examination by the physician involved a simple BP
examination revealing an abnormally low reading of 94/62;
auscultation revealed abnormal heart sounds. The patient was
referred to a cardiologist who undertook further tests and diag-
nosed aortic valve stenosis. The patient was listed for urgent open
heart surgery three days later, involving aortic valve replacement.
The patient made a full recovery and returned to performing after
three months. His thoracic and arm symptoms were fully resolved
following the surgery.
4. Case study 3
A 72 year old woman with confirmed cervical spondylosis was
referred for physiotherapy for persistent neck pain (4e6/10 VAS).
She was also under the care of the vascular department for exercise
induced ischaemic leg pain related to atherosclerosis and was on
medication for hypertension and hyperlipidaemia. Physiotherapy
treatment involving longitudinal manual traction seemed to give
temporary relief (at the time). However, she reported increased
pain following treatment, together with symptoms of feeling
unwell (dizzy/faint/agitated) for a period of 24 h. This response was
described (in the notes) as ‘treatment soreness’and manual therapy
was continued. A similar response followed over the next three
treatment sessions, with only minor improvements in neck pain.
When she reported her experience to the vascular surgeon on
a routine check-up, he examined her BP which was recorded as 155/
95 and auscultated her carotid arteries (revealing an abnormal
bruit). Duplex ultra-sound of her carotid arteries revealed advanced
stenosis due to atherosclerosis and she was listed for urgent carotid
endarterectomy. She made a complete recovery and incidentally
reported that her neck pain had reduced to 1e2/10. The surgeon
suggested based on the history and operative findings, that she had
been reporting “manual therapy induced transient ischaemic
attacks (TIA)”. She was able to self-manage her residual neck pain
and reported no further episodes of TIA.
5. Clinical reasoning and implications
The above case studies illustrate how manual therapists may use
vascular pattern recognition to assess risk and consider BP as
a clinical test to guide assessment and management. The first case
was a patient with obvious cardio-vascular risk factors. In addition,
clinical observation revealed that she may have been presenting
with at worst stroke/TIA or at best cranial nerve (V and VIIeXII)
involvement. The observed facial asymmetry and prominent
carotid artery were indicative of possible ischaemia, with potential
underlying aneurysm or dissection. This required a different
approach to assessment. With the initial test revealing a danger-
ously high BP, it was felt that further examination of neurological
A.J. Taylor, R. Kerry / Manual Therapy 18 (2013) 351e353352
status should be performed in a safe environment and she was
referred immediately to accident and emergency. Standard manual
therapy examination in this case (i.e. active/passive range of motion
etc.) was not appropriate and may have constituted risk to the
patient. Interestingly, following further investigations (Duplex
ultra-sound) and stabilisation of her BP she was able to be assessed
conventionally and treated successfully without incident.
Case two illustrates a young apparently fit active male with no
known risk factors (excepting the brain aneurysm aged 11), who
presented with NMS symptoms which were actually the early
presentation of an unusual but life threatening cardiac condition.
This was revealed eventually by the detection of an abnormally
low BP taken in the clinic. In this case further manual therapy
was entirely inappropriate. The increasing feeling of near
syncope may have been a manifestation of brain ischaemia at
a time of effort (i.e. running during Frisbee or performing
onstage) which has been proposed within the vascular literature
(Spirito et al., 2009). The operating surgeon concurred, suggest-
ing that “sudden death could have occurred in this patient at any
time”.
Case three was a patient with frank neurological signs due to
brain ischaemia e.g. transient ischaemic events (short term
ischaemia), memory loss and disequilibrium. This together with her
history of confirmed lower limb atherosclerosis and medications
for known hypertension/hyperlipidaemia, made her a likely
candidate for more widespread vascular pathology. Carotid or
vertebrobasilar artery disease should be considered as a potential
underlying pathology in patients with such a profile. As such,
logically, manual therapists should consider blood pressure as an
appropriate examination technique.
6. Conclusion and recommendations
The authors present three NMS cases which support the
contention that BP recording is an appropriate objective test for
manual therapists prior to conventional assessment or interven-
tion. The results of BP testing may provide direction for risk
assessment and/or the management of patients across populations.
Vascular profiling may enhance the risk assessment and clinical
reasoning process for manual therapists who treat NMS cases.
Manual therapy clinicians should incorporate consideration of the
vascular system and its related pathologies as a whole, rather than
any one component part.
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... Arterial Dysfunction Prior to Orthopaedic Manual Therapy Intervention 15 advocates the screening of BP as part of the assessment of cervical spine complaints, as have other authors. 17,18 The present study, sought to identify the frequency of blood pressure 19 and are identified in the Australian National Health Survey as health determinants that are related to the onset and severity of chronic disease. 6,20 The VU Osteopathy Clinic (Australia) is a student-led teaching clinic for osteopathy students at two locations; central Melbourne City and St Albans. ...
... Taylor and Kerry 18 showed the relevance of BP measurement in manual therapy by presenting three different case studies of patients, presenting to manual therapists with a complaint of cardiovascular origin. These patients varied in age (32, 56 & 72 years of age) and presentation. ...
... This clinical data suggests that it is necessary for manual therapists to conduct BP readings and other medical examinations, on all patients who present to their practice, as cardiovascular complications can manifest as musculoskeletal complaints. 18 The current results suggest that routine screening of BP by osteopaths would be of value from a M A N U S C R I P T ...
Blood pressure screening in an Australian osteopathy student-led clinic
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Objectives: Approximately 25% of the Australian population are hypertensive, contributing 5% to the total burden of disease in Australia. The measurement of blood pressure (BP) and management of hypertension is relatively straightforward, and is a modifiable risk factor for cardiovascular disease. Given the prevalence of hypertension in the community, osteopaths are in a position to be able to measure BP and do so in routine practice. The present study sought to identify the frequency of blood pressure measurement of patients attending a student-led osteopathy clinic. Method: New patients attending the Victoria University (VU) Osteopathy Clinic between March and June 2016 completed a demographic and health information questionnaire prior to their initial consultation. During the initial consultation students are asked to measure the patients BP and record this in the clinical history, this is a routine part of their standard osteopathy consultation. Results: BP measurements were available for 31.2% (n = 129) of new patients attending the VU Osteopathy Clinic, 68.8% of new patients did not have BP measurements recorded. Of those patients whose blood pressure was recorded, approximately 25% were classified as hypertensive. Age, gender and cardiovascular history did not appear to influence whether BP was recorded. Conclusions: Nearly 70% of patients did not have their BP recorded. Future research should evaluate the reasons for student osteopaths not measuring and/or recording new patients BP, and whether these reasons are modifiable. Changes in the curricula and training of clinical educators may be required to increase the clinical practice of measuring BP in student-led clinics.
View
... A case like this raises the issue of whether physiotherapists should include further testing not routinely applied by the profession. Taylor and Kerry [26] suggested that a 'vascular profiling' of all patients through measuring their blood pressure and heart rate would aid clinical reasoning and decision-making. This notion is further supported by Severin et al. [27] who suggest that physiotherapists should routinely measure blood pressure. ...
Perimyocarditis presenting as thoracic spinal pain in a physiotherapy outpatient clinic – a case report
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  • Oct 2022
Objective To highlight the necessity for on-going vigilance of serious pathology when assessing and managing people with spinal pain. Methods A case report of a young male patient who sought physiotherapy treatment for his acute thoracic pain. Following physiotherapy assessment, it seemed unlikely that the pain was related to a musculoskeletal problem. Besides pain-induced vomiting, there were no overt signs of serious pathology. However, he had a family history of cardiac issues. The patient was referred back to his general practitioner (GP) for further assessment. Results The patient was subsequently diagnosed with perimyocarditis following investigations and was treated accordingly. At 6, 12 and 24 months follow-up, he reported good health. Conclusions and impact statement Physiotherapists must remain vigilant of serious pathology even if patients have been examined by other healthcare professionals. This case also raises the issue of whether ‘vascular profiling’ should be part of routine practice protocols.
View
... Considerations, precautions, and contraindications of spinal manipulation to reduce the potential for the occurrence of AEs have been reported (Pettman 2006). For example, the occurrence of serious AEs with thrust manipulation to the cervical spine is estimated to be between 1 per 400,000 to 3e6 per 10 million (Haldeman et al., 1999;Hurwitz et al., 1996;Rushton et al., 2014;Taylor and Kerry, 2013;Kerry & Taylor 2006Kerry et al., 2008;Kerry et al. 2008Kerry et al. , 2008Shekelle et al., 1992). ...
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Methods We performed a systematic review of potential adverse events (AEs) of manual therapy to peripheral joints using PubMed, CINAHL, PEDro, AMED, and Google Scholar with a single term for each peripheral body region (shoulder, elbow, wrist, hand, hip, knee, ankle, foot). Inclusion criteria included articles that examined or reported the occurrence of AEs. Exclusion criteria included literature discussing treatment other than manual therapy or surgery. Results Twenty total articles meeting the inclusion criteria were found. A total of fifty-three adverse events were analyzed. Most AEs were benign. Little evidence exists for serious AEs with manual therapy. Scant serious AEs were reported with acupuncture or massage near the shoulder, hip, and knee. Discussion AEs with manual therapy to the spine have garnered ample attention in literature. Traditional manual therapy consists of joint mobilization, thrust manipulation, and a variety of soft tissue techniques. However, with the popularity of other “manual therapies”, outside the traditional definition, the practitioner and client should be aware of the risks. Conclusion AEs occurring with most manual therapy techniques to the peripheral joints are transient and mild. It is difficult to attribute true AEs to manual therapy in multi-modal treatment paradigms with numerous single session interventions. Since there are no international definitions or classifications of AEs, and the definition of manual.
View
... 3,4 Large epidemiological studies and analyses specific to physical therapy have demonstrated that HTN and other cardiovascular risk factors occur frequently in patients with low back pain, hip and knee osteoarthritis, and other common conditions encountered in physical therapist practice. [5][6][7][8][9] Boissonault demonstrated that of the comorbidities present in patients referred to outpatient physical therapy services, heart disease and its associated risk factors are the most common, and most patients would be classified as having at least moderate risk for heart disease. 10 Unfortunately, HTN is relatively asymptomatic, even at extreme values 11 , which can make awareness, treatment, and effective control difficult. ...
View
... 3,4 Large epidemiological studies and analyses specific to physical therapy have demonstrated that HTN and other cardiovascular risk factors occur frequently in patients with low back pain, hip and knee osteoarthritis, and other common conditions encountered in physical therapist practice. [5][6][7][8][9] Boissonault demonstrated that of the comorbidities present in patients referred to outpatient physical therapy services, heart disease and its associated risk factors are the most common, and most patients would be classified as having at least moderate risk for heart disease. 10 Unfortunately, HTN is relatively asymptomatic, even at extreme values 11 , which can make awareness, treatment, and effective control difficult. ...
Outpatient Physical Therapist Attitudes Toward and Behaviors in Cardiovascular Disease Screening: A National Survey
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Full-text available
Background: Screening the cardiovascular system is an important and necessary component of the physical therapist examination to ensure patient safety, appropriate referral, and timely medical management of cardiovascular disease (CVD) and risk factors. The most basic screening includes a measurement of resting blood pressure (BP) and heart rate (HR). Previous work demonstrated that rates of BP and HR screening and perceptions toward screening by physical therapists are inadequate. Objective: The purpose was to assess the current attitudes and behaviors of physical therapists in the United States regarding the screening of patients for CVD or risk factors in outpatient orthopedic practice. Design: This was a cross-sectional, online survey study. Methods: Data were collected from an anonymous adaptive online survey delivered via an email list. Results: A total of 1812 surveys were included in this analysis. A majority of respondents (n = 931; 51.38%) reported that at least half of their current caseload included patients either with diagnosed CVD or at moderate or greater risk of a future occurrence. A total of 14.8% of respondents measured BP and HR on the initial examination for each new patient. The most commonly self-reported barriers to screening were lack of time (37.44%) and lack of perceived importance (35.62%). The most commonly self-reported facilitators of routine screening were perceived importance (79.48%) and clinic policy (38.43%). Clinicians who managed caseloads with the highest CVD risk were the most likely to screen. Limitations: Although the sampling population included was large and representative of the profession, only members of the American Physical Therapy Association Orthopaedic Section were included in this survey. Conclusions: Despite the high prevalence of patients either diagnosed with or at risk for CVD, few physical therapists consistently included BP and HR on the initial examination. The results of this survey suggest that efforts to improve understanding of the importance of screening and modifications of clinic policy could be effective strategies for improving rates of HR and BP screening.
View
... 3,4 Large epidemiological studies and analyses specific to physical therapy have demonstrated that HTN and other cardiovascular risk factors occur frequently in patients with low back pain, hip and knee osteoarthritis, and other common conditions encountered in physical therapist practice. [5][6][7][8][9] Boissonault demonstrated that of the comorbidities present in patients referred to outpatient physical therapy services, heart disease and its associated risk factors are the most common, and most patients would be classified as having at least moderate risk for heart disease. 10 Unfortunately, HTN is relatively asymptomatic, even at extreme values 11 , which can make awareness, treatment, and effective control difficult. ...
Outpatient Physical Therapist Attitudes Toward and Behaviors in Cardiovascular Disease Screening: A National Survey
Article
Full-text available
  • Mar 2019
Screening the cardiovascular system is an important and necessary component of the physical therapist examination to ensure patient safety, appropriate referral, and timely medical management of cardiovascular disease (CVD) and risk factors. The most basic screening includes a measurement of resting blood pressure (BP) and heart rate (HR). Previous work demonstrated that rates of BP and HR screening and perceptions toward screening by physical therapists are inadequate. Objective The purpose of this study was to assess the current attitudes and behaviors of physical therapists in the United States regarding the screening of patients for CVD or risk factors in outpatient orthopedic practice. Design This is a cross-sectional, online survey study. Methods Data were collected from an anonymous adaptive online survey delivered via an email list. Results A total of 1812 surveys were included in this analysis. Most respondents (n = 931; 51.38%) reported that at least half of their current caseload included patients either with diagnosed CVD or at moderate or great risk of a future occurrence. A total of 14.8% of respondents measured BP and HR on the initial examination for each new patient. The most commonly self-reported barriers to screening were lack of time (37.44%) and lack of perceived importance (35.62%). The most commonly self-reported facilitators of routine screening were perceived importance (79.48%) and clinic policy (38.43%). Clinicians who managed caseloads with the highest CVD risk were the most likely to screen. Limitations Although the sampling population included was large and representative of the profession, only members of the APTA orthopedic section were included in this survey. Conclusions Despite the high prevalence of patients either diagnosed with or at risk for CVD, few physical therapists consistently included BP and HR on the initial examination. On the basis of the results of this survey, efforts to improve understanding regarding the importance of screening and modifications of clinic policy may be effective strategies for improving rates of HR and BP screening.
View
... 3,4 Large epidemiological studies and analyses specific to physical therapy have demonstrated that HTN and other cardiovascular risk factors occur frequently in patients with low back pain, hip and knee osteoarthritis, and other common conditions encountered in physical therapist practice. [5][6][7][8][9] Boissonault demonstrated that of the comorbidities present in patients referred to outpatient physical therapy services, heart disease and its associated risk factors are the most common, and most patients would be classified as having at least moderate risk for heart disease. 10 Unfortunately, HTN is relatively asymptomatic, even at extreme values 11 , which can make awareness, treatment, and effective control difficult. ...
View
... measuring blood pressure) in younger people may not be particularly useful for manual therapists when aiming to determine the risks of serious adverse events in these patients (Thomas et al., 2011(Thomas et al., , 2017. In older patients, measuring blood pressure may be considered, since hypertension is a recognised risk factor for both stroke and cardiovascular disease (Taylor and Kerry, 2013;Traenka et al., 2017). However, the diagnostic validity and reliability of blood pressure measurement (in addition to the patient interview) with regard to assessing vascular risk factors in manual therapy practice is unknown and needs further investigation. ...
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Manipulation and mobilisation of the cervical spine are well established interventions in the management of patients with headache and/or neck pain. However, their benefits are accompanied by potential, yet rare risks in terms of serious adverse events, including neurovascular insult to the brain. A recent international framework for risk assessment and management offers directions in the mitigation of this risk by facilitating sound clinical reasoning. The aim of this article is to critically reflect on and summarize the current knowledge about cervical spine manual therapy and to provide guidance for clinical reasoning for cervical spine manual therapy.
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Article
  • Feb 2017
Background: Some normotensive patients can have a spike in resting systolic blood pressure (SBP) in response to acute neck pain. Applying the typical dosage of mobilization may potentially result in a sympatho-excitatory response, further increasing resting SBP. Therefore, there is a need to explore other dosage regimens that could result in a decrease in SBP. Objectives: To compare the blood pressure (BP) and heart rate (HR) response of pain-free, normotensive adults when receiving unilateral posterior-to-anterior mobilization (PA) applied to the neck versus its corresponding placebo (PA-P). Study design: Double-Blind, Randomized Clinical Trial. Methods: 44 (18 females) healthy, pain-free participants (mean age, 23.8 ± 3.04 years) were randomly allocated to 1 of 2 groups. Group 1 received a PA-P in which light touch was applied to the right 6th cervical vertebra. Group 2 received a PA to the same location. BP and HR were measured prior to, during, and after the application of PA or PA-P. A mixed-effect model of repeated measure analysis was used for statistical analysis. Results: During-intervention, the PA group had a significant reduction in SBP, while the placebo group had an increase in SBP. The change in SBP during-intervention was significantly different between the PA and the placebo group (p-value = 0.003). There were no significant between-group differences found for HR and diastolic BP (DBP). The overall group-by-time interaction was statistically significant for SBP (p-value = 0.01). Conclusions: When compared to placebo, the dosage of applied PA resulted in a small, short-lived drop in SBP not exceeding the minimal detectable change. Trial registered at Germanctr.de (DRKS00005095).
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A ‘system based’ approach to risk assessment of the cervical spine prior to manual therapy
Article
Full-text available
This paper presents a clinical overview and update of cervical arterial dysfunction (CAD) for osteopaths and other clinicians who treat patients presenting with cervical pain and headache syndromes. An overview of a ‘system based’ approach to the concept of vertebrobasilar arterial insufficiency (VBI) is covered, with reference to assessment procedures recommended by commonly used guidelines. We suggest that the evidence supporting contemporary practice remains limited and present a more holistic approach to considering cervical arterial dysfunction. This ‘system based’ approach considers typical pain patterns and clinical progressions of both vertebrobasilar, and internal carotid arterial pathologies. Attention to the risk factors, pathomechanics and haemodynamics of arterial dysfunction is also given. We suggest that consideration of the information provided in this updated ‘Masterclass’ will enhance clinical reasoning with regard to differential diagnosis of cervical pain syndromes and prediction of serious adverse reactions to treatment.
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Blood Pressure Measurement Guidelines for Physical Therapists
Article
Full-text available
  • Jun 2011
Vital sign measurement and assessment are important components of the review of systems in a physical therapy examination for individuals with and without documented cardiopulmonary disease. The measurement of blood pressure gives the therapist information regarding the patient's baseline cardiovascular status, response to exercise/activity, and guides exercise prescription. Accurate measurement of blood pressure is critical for making appropriate clinical decisions especially if physical therapists wish to play an important role as primary health care providers. The purpose of this paper is to present recommended guidelines for blood pressure measurement by physical therapists and physical therapist assistants.
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Internal carotid artery dissection
Article
  • Jan 2011
stv.2011.0593 Auteur(s) : Marie-Pierre Gobin-Metteil1 gobin-metteil@ch-sainte-anne.fr, Emmanuel Touze2 e.touze@ch-sainte-anne.fr, Olivier Naggara1, Sylvie Godon-Hardy1, Jean-Francois Meder1 1 CH Sainte-Anne, Imagerie morphologique et fonctionnelle, 1 rue Cabanis, 75014 Paris, France 2 CH Sainte-Anne, Neurologie, 1 rue Cabanis, 75014 Paris, France Monsieur C., 35 ans, est admis pour hemiparesie droite s’aggravant secondairement avec hemiplegie et aphasie. L’IRM initiale visualise une [...]
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Should we abandon cervical spine manipulation for mechanical neck pain? Yes
Article
Benedict Wand and colleagues argue that the risks of cervical spine manipulation are not justified, but David Cassidy and colleagues (doi:10.1136/bmj.e3680) think it is a valuable addition to patient care Cervical spine manipulation (a high velocity, low amplitude, end range thrust manoeuvre) is a common treatment option for mechanical neck pain yet may carry the potential for serious neurovascular complications, specifically vertebral artery dissection and subsequent vertebrobasilar stroke. The non-superiority of manipulation to alternative treatments, coupled with concerns regarding safety, renders cervical spine manipulation unnecessary and inadvisable. The controversy surrounding the association between manipulation and neurovascular complications is longstanding and not fully resolved, partly because it is difficult to obtain conclusive evidence on rare adverse events. What can be accepted is that the incidence of vertebral artery dissection is low, with estimates between 1 (95% confidence interval 0.5 to 1.4) and 1.7 (1.1 to 2.3) per 100 000 person years in the United States.1 The estimates for stroke resulting from vertebral artery dissection are lower still, ranging from 0.75 to 1.12 per 100 000 person years,2 and many are unlikely to be the result of cervical …
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Increases in morbid obesity in the USA: 2000-2005
Article
Background: It is well known that citizens of developed countries are more likely to be overweight than they were 20 years ago. The most serious health problems are not associated with overweight or moderate obesity, however, but with clinically severe or morbid obesity (e.g. more than 100 pounds (45kg) overweight). There is no reason to expect that morbid obesity trends parallel overweight or moderate obesity. If morbid obesity is a rare pathological condition that has biological causes, the more than 10-fold increase in bariatric surgery procedures over the past eight years in the USA could have even lowered the prevalence of morbid obesity-and may very well stem the problem in other countries. Objective: To estimate trends for extreme weight categories (BMI>40 and >50) for the period between 1986 and 2005 in the USA, and to investigate whether trends have changed since 2000. Methods: Data from The Behavioral Risk Factor Surveillance System (a random-digit telephone survey of the household population of the USA), for the period from 1986 to 2005, were analysed. The main outcome measure was body mass index (BMI), calculated from self-reported weight and height. Results: From 2000 to 2005, the prevalence of obesity (self-reported BMI over 30) increased by 24%. However, the prevalence of a (self-reported) BMI over 40 (about 100 pounds (45kg) overweight) increased by 50% and the prevalence of a BMI over 50 increased by 75%, two and three times faster, respectively. The heaviest BMI groups have been increasing at the fastest rates for 20 years. Conclusions: The prevalence of clinically severe obesity is increasing at a much faster rate among adults in the USA than is the prevalence of moderate obesity. This is consistent with the public health idea that the population weight distribution is shifting, which disproportionately increases extreme weight categories. Because comorbidities and resulting service use are much higher among severely obese individuals, the widely published trends for overweight/obesity underestimate the consequences for population health. The aggressive and costly expansion of bariatric surgery in recent years has had no visible effect on containing morbid obesity rates in the USA.
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Treatment Issues in Spontaneous Cervicocephalic Artery Dissections
Article
The management of cervicocephalic arterial dissections raises many unsolved issues such as: how to best acutely treat patients who present with ischemic stroke or occasionally with sub-arachnoid hemorrhage? How to best prevent ischemic stroke in patients who present with purely local signs such as headache, painful Horner Syndrome or neck pain? How long and how should patients be treated after cervicocephalic arterial dissections? Can patients resume their sports activities and when? The consensus is that, given the well-established initial thromboembolic risk, an urgent antithrombotic treatment is required in patients with a recent nonhemorrhagic cervicocephalic arterial dissection, but the type of antithrombotic treatment - anticoagulants or aspirin - as well as the indication for a local arterial treatment such as angioplasty/stenting remain debated. Evidence from a randomized clinical trial would be welcome but such a trial raises major issues of methodology, feasibility and funding. Meanwhile, cervicocephalic arterial dissection remains a situation when a bedside clinician should use, on a case-by-case basis, best clinical judgment and adopt a stepped care approach in the minority of patients who deteriorate despite initial treatment.
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Risk factors and clinical features of craniocervical arterial dissection
Article
  • Aug 2011
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).
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