Vascular profiling: should manual therapists take blood pressure?

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.

Cervical arterial dysfunction: knowledge and reasoning for manual physical therapists.

SYNOPSIS: This clinical commentary provides evidence-based information regarding adverse cerebrovascular events in the context of manual therapy assessment and management of the cervical spine. Its aim is to facilitate clinical decision making during diagnosis and treatment of patients presenting to the therapist with cervicocranial pain. Rather than focusing on a traditional view of premanipulative testing as the cornerstone for decision making, we present information concerning the clinical presentation of specific vascular conditions. Additionally, we discuss the assessment and management of musculoskeletal pain in the presence of risk factors for cerebrovascular accident. It is proposed that vascular "red flag" presentations mimic neuromusculoskeletal cervicocranial syndromes. Invariably, the 2 conditions coexist. This reasoning presupposes that some patients who have poor clinical outcomes, or a serious adverse response to treatment, may be those who actually present with undiagnosed vascular pathology. We use 2 case reports to demonstrate how incorporating vascular knowledge into clinical reasoning processes may influence clinical decision making. LEVEL OF EVIDENCE: Level 5.

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.

Cervical arterial dysfunction assessment and manual therapy.

In this paper, we present a clinical overview of cervical arterial dysfunction (CAD) for manual therapists who treat patients presenting with cervical pain and headache syndromes. An overview of vertebrobasilar arterial insufficiency (VBI) is given, with reference to assessment procedures recommended by commonly used guidelines. We suggest that the evidence supporting contemporary practice is limited and present a more holistic, evidence-based approach to considering CAD. This approach considers typical pain patterns and clinical progressions of both vertebrobasilar, and internal carotid arterial pathologies. Attention to the risk factors and pathomechanics of arterial dysfunction is also given. We suggest that consideration of the information provided in this Masterclass will enhance the manual therapist's clinical reasoning with regard to differential diagnosis of cervical pain syndromes, and prediction of serious adverse reactions to treatment.

Low blood lead levels do not appear to be further reduced by dietary supplements.

OBJECTIVE: Our objective was to evaluate the association of dietary intakes of selected micronutrients and blood lead (PbB) concentrations in female adults and in children. DESIGN: With longitudinal monitoring, we measured daily intakes of the micronutrients calcium, magnesium, sodium, potassium, barium, strontium, phosphorus, zinc, iron (limited data), and copper from 6-day duplicate diets (2-13 collections per individual) and PbB concentrations. Participants were three groups of females of child-bearing age (one cohort consisting of 21 pregnant subjects and 15 nonpregnant controls, a second cohort of nine pregnant migrants), and one group of 10 children 6-11 years of age. RESULTS: Mean PbB concentrations were <5 microg/dL. A mixed linear model that included only group and time accounted for 5.9% of the variance of the PbB measurements; neither the effect of time nor the effect of group was significant. The model containing all of the micronutrients (except iron, for which there was a great deal of missing data), along with time and group, accounted for approximately 9.2% of the variance of PbB; this increase was not statistically significant. There was, however, a significant association of PbB with phosphorus, magnesium, and copper when all micronutrients were included in the statistical analysis, perhaps reflecting a synergistic effect. CONCLUSIONS: In contrast to most previous studies, we found no statistically significant relationships between the PbB concentrations and micronutrient intake. In adults and older children with low PbB concentrations and minimal exposure to Pb, micronutrient supplementation is probably unnecessary.

Blood lead changes during pregnancy and postpartum with calcium supplementation.

Pregnancy and lactation are times of physiologic stress during which bone turnover is accelerated. Previous studies have demonstrated that there is increased mobilization of lead from the maternal skeleton at this time and that calcium supplementation may have a protective effect. Ten immigrants to Australia were provided with either calcium carbonate or a complex calcium supplement (approximately 1 g/day) during pregnancy and for 6 months postpartum. Two immigrant subjects who did not conceive acted as controls. Sampling involved monthly venous blood samples throughout pregnancy and every 2 months postpartum, and quarterly environmental samples and 6-day duplicate diets. The geometric mean blood lead at the time of first sampling was 2.4 microg/dL (range, 1.4-6.5). Increases in blood lead during the third trimester, corrected for hematocrit, compared with the minimum value observed, varied from 10 to 50%, with a geometric mean of 25%. The increases generally occurred at 6-8 months gestation, in contrast with that found for a previous cohort, characterized by very low calcium intakes, where the increases occurred at 3-6 months. Large increases in blood lead concentration were found during the postpartum period compared with those during pregnancy; blood lead concentrations increased by between 30 and 95% (geometric mean 65%; n = 8) from the minimum value observed during late pregnancy. From late pregnancy through postpartum, there were significant increases in the lead isotopic ratios from the minimum value observed during late pregnancy for 3 of 8 subjects (p < 0.01). The observed changes are considered to reflect increases in mobilization of lead from the skeleton despite calcium supplementation. The identical isotopic ratios in maternal and cord blood provide further confirmation of placental transfer of lead. The extra flux released from bone during late pregnancy and postpartum varies from 50 to 380 microg lead (geometric mean, 145 microg lead) compared with 330 microg lead in the previous cohort. For subjects replete in calcium, the delay in increase in blood lead and halving of the extra flux released from bone during late pregnancy and postpartum may provide less lead exposure to the developing fetus and newly born infant. Nevertheless, as shown in several other studies on calcium relationships with bone turnover, calcium supplementation appears to provide limited benefit for lead toxicity during lactation.