Should we abandon positional testing for vertebrobasilar insufficiency?

Screening for Vertebrobasilar pathology and upper cervical instability by physical therapists treating neck pain: a retrospective chart review

INTRODUCTION

Vertebrobasilar vascular pathology and upper cervical ligament instability may contraindicate the use of cervical manual therapy. We examined physical therapists' documentation of screening for these conditions and hypothesized screening would be more common with specific risk factors and when using manual therapy.

METHODS

This chart review included adults with neck pain presenting for outpatient physical therapy from 2015-2021. Exclusions were age<18 and history of cervical spine surgery. Demographics, vertebrobasilar and upper cervical ligament instability screening questions and examination tests, risk factors (i.e. hypertension, whiplash), and use of manual therapy were extracted.

RESULTS

260 patients were included (mean age ± standard deviation 59.6 ± 16.2 years, 70.8% female). Physical therapists infrequently administered vertebrobasilar and upper cervical ligament instability tests (each<14%). Screening questions were generally more common (e.g. headache, visual disturbances; each>13%). There was no significant difference in any frequency of screening method given the presence of hypertension, whiplash, or use of manual therapy (p > .05 for each).

CONCLUSION

In the present study, physical therapists infrequently documented performance of vertebrobasilar or upper cervical ligament instability screening for adults with neck pain, even in the presence of risk factors or preceding manual therapy. Further research should corroborate these findings and explore reasons for use/avoidance of screening.

Pre-manipulative cervical spine testing and sustained rotation do not influence intracranial hemodynamics: an observational study with transcranial Doppler ultrasound

INTRODUCTION

Manual joint mobilization and manipulation are recommended therapeutic interventions for people with neck pain. High-velocity thrust and sustained techniques have an uncertain association with serious arterial trauma. The validity of pre-manipulative tests of the cervical spine is often questioned, and the understanding of the effect of head/neck position on blood flow is still incomplete. Most of the evidence concerning hemodynamics in this area relates to extracranial flow (vertebral and carotid artery). Less is understood about the effects on intracranial flow while performing pre-manipulative tests and sustained positions like end of range cervical rotation mobilization. The aim of the study was to assess the influence of commonly used evaluation and treatment positions on intracranial hemodynamic parameters.

METHOD

A randomized, cross-over observational study using ultrasonography on healthy subjects (n = 19) was conducted to measure hemodynamic parameters (peak systolic velocity and end diastolic maximum) of intracranial arterial systems. Two test positions (sustained pre-manipulative thrust C0-1 and sustained cervical end of range rotation) were compared with a sham position for each test position.

RESULTS

:Neither the sequence of tests performed nor an independent variable (the two positions) had a significant effect (p < 0.05) on peak systolic velocity (PSV) or end diastolic maximum (EDM).

DISCUSSION

No effects from commonly used assessment and treatment of neck positions on hemodynamic parameters were found. This is consistent with previous studies. Further study is indicated on people with symptoms and known pathologies.

Knowledge, beliefs, and attitudes of spinal manipulation: a cross-sectional survey of Italian physiotherapists

BACKGROUND AND OBJECTIVE

High-velocity low-amplitude thrust spinal manipulation (SM) is a recommended and commonly used manual therapy intervention in physiotherapy. Beliefs surrounding the safety and effectiveness of SM have challenged its use, and even advocated for its abandonment. Our study aimed to investigate the knowledge and beliefs surrounding SM by Italian physiotherapists compared with similar practitioners in other countries.

METHODS

An online survey with 41 questions was adapted from previous surveys and was distributed via a mailing list of the Italian Physiotherapists Association (March 22-26, 2020). The questionnaire was divided into 4 sections to capture information on participant demographics, utilization, potential barriers, and knowledge about SM. Questions were differentiated between spinal regions. Attitudes towards different spinal regions, attributes associated with beliefs, and the influence of previous educational background were each evaluated.

RESULTS

Of the 7398 registered physiotherapists, 575 (7.8%) completed the survey and were included for analysis. The majority of respondents perceived SM as safe and effective when applied to the thoracic (74.1%) and lumbar (72.2%) spines; whereas, a smaller proportion viewed SM to the upper cervical spine (56.8%) as safe and effective. Respondents reported they were less likely to provide and feel comfortable with upper cervical SM (respectively, 27.5% and 48.5%) compared to the thoracic (respectively, 52.2% and 74.8%) and lumbar spines (respectively, 46.3% and 74.3%). Most physiotherapists (70.4%) agreed they would perform additional screening prior to upper cervical SM compared to other spinal regions. Respondents who were aware of clinical prediction rules were more likely to report being comfortable with SM (OR 2.38-3.69) and to perceive it as safe (OR 1.75-3.12). Finally, physiotherapists without musculoskeletal specialization, especially those with a traditional manual therapy background, were more likely to perform additional screening prior to SM, use SM less frequently, report being less comfortable performing SM, and report upper cervical SM as less safe (p < 0.001).

DISCUSSION

The beliefs and attitudes of physiotherapists surrounding the use of SM are significantly different when comparing the upper cervical spine to other spinal regions. An educational background in traditional manual therapy significantly influences beliefs and attitudes. We propose an updated framework on evidence-based SM.

Assessing Cranial Nerves in Physical Therapy Practice: Findings from a Cross-Sectional Survey and Implication for Clinical Practice

BACKGROUND AND OBJECTIVE

Serious pathologies of the neck can potentially result in cranial nerve palsy. Knowledge about cranial nerve examination (CNE) seems sparse, and its use is still unknown. We aim to investigate the knowledge, skills, and utilization of CNE of Italian physiotherapists.

MATERIALS AND METHODS

An online cross-sectional survey.

RESULTS

396 completed the survey, reaching the required sample size. Although Italian physiotherapists consider CNE relevant (mean ± SD = 7.6/10 ± 2.0), over half of all responders (n = 229 (57.8%)) were not trained in the fundamentals and around a third did not use it in their daily practice (n = 138 (34.8%)). Additionally, participants were unconfident and insecure in conducting (n = 152 (38.4%) and n = 147 (37.1%)), interpreting (n = 140 (35.4%) and n = 164 (41.4%)), and managing the CNE (n = 141 (35.6%) and n = 154 (38.9%)). Possessing a musculoskeletal specialization was associated with an increased value attributed to clinical practice guidelines and reduced the lack of confidence in conducting, interpreting, and managing the CNE (respectively, n = 35 (25.5%), p = 0.0001; n = 32 (23.4%) p = 0.0002; n = 32 (23.4%) p = 0.0002). Working in a direct access setting significantly increased the considered relevance of guidelines and the concerns about arterial (p = 0.004) and other serious pathologies (p = 0.021). Pain and visual disturbances were considered the main indicators to CNE, demonstrating limited knowledge of signs and symptoms' indicating CNE. Participants considered specific training in CNE as relevant (mean ± SD = 7.6/10 = 2.1).

CONCLUSIONS

a substantial proportion of Italian physiotherapists are not schooled in the fundamentals of cranial nerve examination. Given the number of physiotherapists who work in first contact roles, this is a professional concern.

Factors associated with cervical arterial dysfunction: a survey of physical therapist educators in the United States

Objectives: The purpose of this study was to identify the key constructs associated with symptom description and behavior, natural history of complaints, and previous medical history of cervical arterial dysfunction (CAD) according to a panel of physical therapist (PT) educators. Methods: An electronic survey was conducted of licensed PT educators currently involved in musculoskeletal physical therapy education within a credentialed program. Survey prompts queried educators to list the subjective and objective items associated with CAD, in open-text format. Responses were coded to identify unique themes (constructs). Principal axis factor analysis with Varimax rotation was performed to identify underlying constructs associated with CAD according to the panel of educators. Results: Seventy-two educators completed the survey (24.2% response rate) resulting in 50 identified unique items through thematic coding. Factor analysis (Kaiser-Meyer-Olkin measure of sampling adequacy = .679, Bartlett's test of sphericity (x ²(351) = 1129.06. p < .001), resulted in a four-factor solution: '5Ds and 3 Ns,' 'Other Neurological Findings,' 'Signs & Symptoms in Rotation and/or Extension,' and 'General Health.' Discussion: According to the PT educators in this study, the factors associated with CAD appear to reflect the IFOMPT guidelines. The responses and subsequent factor analysis demonstrate the lack of any one clinical finding for the identification of CAD in a patient with neck pain. Level of Evidence: V.