Section 1: Context to assessment of the cervical region

International Framework for Examination of the Cervical Region

IFOMPT

The vision of IFOMPT is for worldwide promotion of excellence and unity in clinical and academic standards for manual/musculoskeletal physiotherapists, with its mission statement including to work towards international unity/conformity of educational standards of practice amongst manual/musculoskeletal physiotherapists. The process of development of this framework has been guided by this vision and mission, commencing with an exploration of the key issues in 2007.

Process of development

At the World Confederation for Physical Therapy Congress in Vancouver (2007) IFOMPT coordinated a session of speakers and discussion titled ‘VBI [vertebro-basilar insufficiency] session’ to address a topic that generates frequent questions from Member Organisations of IFOMPT and individual physical therapists. The session involved much discussion about pre-manipulative screening in the cervical spine, and as a result of the session, the IFOMPT Standards Committee was asked to take the key issues forward. At the request of the Standards Committee, a survey using a questionnaire regarding pre-manipulative screening was carried out (DR/LC). The questionnaire was sent to all Member Organisations and Registered Interest Groups (RIGs) of IFOMPT in late 2007. Results of the survey were presented at the IFOMPT Conference in Rotterdam in 2008. In addition, a discussion forum was facilitated in Rotterdam (AR) and contributed to by the development team (DR/LC/TF/WH/RK), involving a nominated expert from each MO. The forum concluded that the development of an agreed international framework was required to inform OMT practice in this area.

Key findings from the 2007 survey[1]

Twenty Member Organisations (100%) and 2 RIGs responded. MO membership varied between countries with 7 small (≤100), 8 moderate (101-399), and 5 large (≥400). Seven Member Organisations (35%) had their own guidelines or protocol, and 10 Member Organisations (50%) and 1 RIG essentially used that of another country (9 Member Organisations reported using those from Australia, and 1 reported using those from the UK). Thus, the majority of Member Organisations (85%) used pre-manipulative guidelines, with the Australian guidelines commonly adopted internationally. Only 5 (25%) Member Organisations had a patient information sheet about cervical manipulation and its risks. Eight Member Organisations (40%) and 1 RIG recommended warning patients about the small risk of stroke and death, while 3 Member Organisations recommended informing re stroke only. Therefore provision of information re serious adverse responses was not standard practice in all countries. Only 3 Member Organisations were aware of cases of stroke attributed to a manipulative physical therapist in their country.

For the physical examination of patients, 17 Member Organisations (85%) and 2 RIGs taught screening positional tests involving extension and rotation (2 using rotation only), and all 20 Member Organisations (100%) and 2 RIGs recommended the use of the sustained pre-manipulative position as a screening test. Fifteen Member Organisations and 1 RIG taught other pre-manipulative screening tests, including: craniovertebral ligament tests (8), dizziness differentiation tests (2), and Hautant’s test (2).

In exploring the use of manipulation in the cervical spine, 8 Member Organisations (40%) and 1 RIG reported that members had decreased the use of manipulation in the upper cervical spine in the last 10 years. Nineteen Member Organisations (95%) and 1 RIG continued to teach upper cervical manipulations, with 3 Member Organisations teaching upper cervical spine manipulations involving end-range rotation. Thirteen Member Organisations (65%) and 1 RIG indicated that the manipulation techniques taught had been changed to limit the amount of rotation used for upper cervical techniques.

It is acknowledged that practice may have changed in some countries since the survey was conducted, but these data provide a useful overview to inform the content of this document.

Key points to emerge from the discussion forum in Rotterdam 2008

The forum in Rotterdam agreed that an international framework was required, and agreed the following points and guiding principles to inform a first draft of a consensus document:

  • Existing documents need to inform development of an international framework. Particularly;
      • Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders[2]
      • Manipulation Association of Chartered Physiotherapists, Cervical Arterial Dysfunction and Manipulative Physiotherapy: information document[3].
  • Inclusion of key aspects of the framework as detailed in the Introduction.
  • Consideration be given to including the pre-manipulative positional test.
  • Consideration be given to including information on craniovertebral ligament testing.
  • Recommendations on informed consent need to be sufficiently flexible for different jurisdictions (to be inclusive of all Member Organisations).
  • Preferred options to be included on manipulative practices.
  • An IFOMPT endorsed document must be:
    • reflective of best practice and research
    • flexible and simple in application
    • legally suitable to individual countries
    • an aid to patient-centred clinical reasoning
    • informative, but NOT prescriptive, when applied to clinical practice.

References

  1. Carlesso L, Rivett D (2011). Manipulative practice in the cervical spine: a survey of IFOMPT member countries. Journal of Manual and Manipulative Therapy 19(2):66-70.
  2. Rivett DA, Shirley D, Magarey M, et al (2006). Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders. Australian Physiotherapy Association: Melbourne.
  3. Kerry R, Taylor AJ, Mitchell J, et al (2007). Manipulation Association of Chartered Physiotherapists, Cervical Arterial Dysfunction and Manipulative Physiotherapy: information document. Available at: http://www.macpweb.org/home/index.php?p=170