The form of causation in health, disease and intervention: biopsychosocial dispositionalism, conserved quantity transfers and dualist mechanistic chains.

Causation is important when considering: how an organism maintains health; why disease arises in a healthy person; and, how one may intervene to change the course of a disease. This paper explores the form of causative relationships in health, disease and intervention, with particular regard to the pathological and biopsychosocial models. Consistent with the philosophical view of dispositionalism, we believe that objects are the fundamental relata of causation. By accepting the broad scope of the biopsychosocial model, we argue that psychological and social constructs be considered objects. We think that this 'biopsychosocial dispositionalism' offers the flexibility required to describe causation throughout health, disease and intervention pathways. When constructing mechanistic chains to describe causative pathways, we argue that an object will causally connect with others through actions; transfers of energy from one object to another, initiated by the manifestation of one or more dispositional property. Finally, our analysis of causative interactions utilises the concept that a common form of interaction exists between disease and intervention pathways. This common form will always be an object, but the mode of interaction will vary with each disease. We describe how intervention may act through objects being shared between converging mechanistic chains, or through the removal and/or insertion of objects in such chains. We believe that this analysis provides novel insight to the forms of causative transactions that can occur. In addition, we hope that the findings of this analysis represent the first step towards developing a framework for appraising the composition of mechanistic theories.

Academic performance and perception of learning following a peer coaching teaching and assessment strategy.

Peer coaching has been associated with positive effects on learning. Specifically, these associations have been explored in complex healthcare professions. A social theory of learning has been proposed as a key component of the utility of peer coaching. Further, within the peer coaching model, assessment has been considered as an important driver. Empirical support for these dimensions of the model is lacking. To quantify assessment achievements and explore emergent attitudes and beliefs about learning related to a specific peer coaching model with integrated assessment. A longitudinal study based in a UK Higher Education Institute recorded assessment achievements and surveyed attitudes and beliefs in consecutive Year 1 undergraduate (physiotherapy) students (n = 560) between 2002 and 2012. A 6% improvement in academic achievement was demonstrated following the introduction of a peer coaching learning model. This was increased by a further 5% following the implementation of an integrated assessment. The improvement related to an overall averaged increase of one marking band. Students valued the strategy, and themes relating to the importance of social learning emerged from survey data. Peer coaching is an evidence-based teaching and learning strategy which can facilitate learning in complex subject areas. The strategy is underpinned by social learning theory which is supported by emergent student-reported attitudes.

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.

Recognition of a patient with neck autonomic dysfunction: findings from a rare case report of harlequin syndrome in direct access physiotherapy.

BACKGROUND: Harlequin syndrome is a rare autonomic condition consisting of unilateral facial flushing and sweating induced by heat, emotion or physical activity. The affected side presents anhidrosis and midline facial pallor due to denervation of the sympathetic fibers. CASE DESCRIPTION: This case describes a patient who reported right-side redness of the face associated with hyperhidrosis during physical activity. She had two previous major motor vehicle accidents. The patient demonstrated difficulties in the visual accommodation of the left eye, but cranial nerve assessment was unremarkable; the patient was then referred to an ophthalmologist, who excluded any autonomic dysfunction as the primary cause of convergence and visual acuity. OUTCOMES: A left-sided sympathetic dysfunction with Harlequin sign diagnosis was made followed by a progressive compensatory adaptation of the right face. The patient was educated and reassured about the benign nature of her problem. DISCUSSION: Knowledge of the autonomic nervous system is still limited in clinical practice. Although challenging, physiotherapists should develop the knowledge and ability needed to perform appropriate assessment of autonomic dysfunctions. CONCLUSION: A dispositional reasoning model should be considered in differential diagnosis.

A modern way to teach and practice manual therapy.

BACKGROUND: Musculoskeletal conditions are the leading contributor to global disability and health burden. Manual therapy (MT) interventions are commonly recommended in clinical guidelines and used in the management of musculoskeletal conditions. Traditional systems of manual therapy (TMT), including physiotherapy, osteopathy, chiropractic, and soft tissue therapy have been built on principles such as clinician-centred assessment, patho-anatomical reasoning, and technique specificity. These historical principles are not supported by current evidence. However, data from clinical trials support the clinical and cost effectiveness of manual therapy as an intervention for musculoskeletal conditions, when used as part of a package of care. PURPOSE: The purpose of this paper is to propose a modern evidence-guided framework for the teaching and practice of MT which avoids reference to and reliance on the outdated principles of TMT. This framework is based on three fundamental humanistic dimensions common in all aspects of healthcare: safety, comfort, and efficiency. These practical elements are contextualised by positive communication, a collaborative context, and person-centred care. The framework facilitates best-practice, reasoning, and communication and is exemplified here with two case studies. METHODS: A literature review stimulated by a new method of teaching manual therapy, reflecting contemporary evidence, being trialled at a United Kingdom education institute. A group of experienced, internationally-based academics, clinicians, and researchers from across the spectrum of manual therapy was convened. Perspectives were elicited through reviews of contemporary literature and discussions in an iterative process. Public presentations were made to multidisciplinary groups and feedback was incorporated. Consensus was achieved through repeated discussion of relevant elements. CONCLUSIONS: Manual therapy interventions should include both passive and active, person-empowering interventions such as exercise, education, and lifestyle adaptations. These should be delivered in a contextualised healing environment with a well-developed person-practitioner therapeutic alliance. Teaching manual therapy should follow this model.

Vascular flow limitations affecting the cervico-cranial region: Understanding ischaemia.

BACKGROUND: Blood flow and brain ischaemia have been of interest to physical therapists for decades. Despite much debate, and multiple publications around risk assessment of the cervical spine, more work is required to achieve consensus on this vital, complex topic. In 2020, the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) Cervical Framework adopted the dubious terminology 'vascular pathologies of the neck', which is misleading, on the premise that 1) not all flow limitations leading to ischaemia, are associated with observable blood vessel pathology and 2) not all blood flow limitations leading to ischaemia, are in the anatomical region of the 'neck'. OBJECTIVE: This paper draws upon the full body of haemodynamic knowledge and science, to describe the variety of arterial flow limitations affecting the cervico-cranial region. DISCUSSION: It is the authors' contention that to apply clinical reasoning and appropriate risk assessment of the cervical spine, there is a requirement for clinicians to have a clear understanding of anatomy/anatomical relations, the haemodynamic science of vascular flow limitation, and related pathologies. This paper describes the wide range of presentations and haemodynamic mechanisms that clinicians may encounter in practice. In cases with a high index suspicion of vascular involvement or an adverse response to assessment/intervention, appropriate referral should be made for further investigations, using consistent terminology. The term 'vascular flow limitation' is proposed when considering the range of mechanisms at play. This fits the terminology used (in vascular literature) at other anatomical sites and is understood by medical colleagues.

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.

What to Look Out for, What to Do, and When: 3 Key Messages for Safely Treating Neck Pain, Headache, and/or Orofacial Symptoms in Musculoskeletal Rehabilitation Settings.

SYNOPSIS: Neck pain, headache, and/or orofacial symptoms are potentially the first (nonischemic) symptoms of an underlying vascular pathology or blood flow limitation. If an underlying vascular pathology or blood flow limitation is not recognized by the musculoskeletal rehabilitation clinician, it can subsequently be aggravated by treatment, raising the risk of serious adverse events. We argue that clinicians can make an important, and potentially lifesaving, difference by providing specific information and advice. This is especially the case in patients with an intermediate level of concern, for example, in patients who only show a few concerning features regarding a possible underlying serious condition and for whom an initial vasculogenic hypothesis was rejected during the clinical reasoning process. We present background information to help the reader understand the context of the problem and suggestions for how clinicians can provide appropriate information and advice to patients who present with neck pain, headache, and/or orofacial symptoms. J Orthop Sports Phys Ther 2023;53(2):59-63. Epub: 28 October 2022. doi:10.2519/jospt.2022.11568.

A guide to identify cervical autonomic dysfunctions (and associated conditions) in patients with musculoskeletal disorders in physical therapy practice.

BACKGROUND: Differential diagnosis is a hot topic in physical therapy, especially for those working in a direct access setting dealing with neck pain and its associated disorders. All international guidelines agree in recommending to first rule out non-musculoskeletal pathologies as the cause of signs and symptoms in the patient. Although the autonomic nervous system (ANS) has a crucial role and is also involved in pain conditions, coverage of it in neuroscience textbooks and educational programmes is limited and most healthcare professionals are unfamiliar with it. Although autonomic conditions are benign in nature, they are clinically of great importance as they may be a 'red flag' warning of an injury along the sympathetic pathway. Therefore, sound knowledge of the ANS system is essential for clinicians. OBJECTIVE: To develop physical therapists' knowledge of and confidence in understanding cervical ANS function and dysfunction, thus enhancing clinical reasoning skills and the pattern recognition process, and performing and interpreting objective examinations. METHODS: This master class provides an introductory guide and essential knowledge to facilitate clinicians to understand cervical autonomic dysfunctions and their clinical evaluation. The optimal referral method is also handled. CONCLUSIONS: Gaining knowledge and understanding of the ANS, its function, its dysfunction, and the related clinical manifestations is likely to lead to a decision-making process driven by 'science and conscience'. This will empower physical therapists to be aware of subtle clues that may be offered by patients during the interview and history intake leading to the appropriate physical examination and triage.

International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention: International IFOMPT Cervical Framework.

SYNOPSIS: This position statement, stemming from the International IFOMPT (International Federation of Orthopaedic Manipulative Physical Therapists) Cervical Framework, was developed based upon the best contemporary evidence and expert opinion to assist clinicians during their clinical reasoning process when considering presentations involving the head and neck. Developed through rigorous consensus methods, the International IFOMPT Cervical Framework guides assessment of the cervical spine region for potential vascular pathologies of the neck in advance of planned interventions. Within the cervical spine, events and presentations of vascular pathologies of the neck are rare but are an important consideration as part of patient examination. Vascular pathologies may be recognizable if the appropriate questions are asked during the patient history-taking process, if interpretation of elicited data enables recognition of this potential, and if the physical examination can be adapted to explore any potential vasculogenic hypothesis. J Orthop Sports Phys Ther 2023;53(1):7-22. Epub: 14 September 2022. doi:10.2519/jospt.2022.11147.

Recognition of Prodromal Hypoglossal Nerve Palsy Presenting with Neck Pain as Primary Complaint: Findings from a Rare Case Report in Direct Access Physiotherapy during the COVID-19 Pandemic.

Neck pain (NP) is the second most common musculoskeletal disorder. Spinal cysts (SCs) are cystic dilatations of the synovial sheaths in joints and tendons. SCs are extremely rare in the cervical spine. Typically, patients are unaware of having an SC due to its asymptomatic nature; however, when cervical SC extends, its volume could compress the surrounding structures, such as the hypoglossal nerve. Isolated hypoglossal nerve palsy (HNP) is very rare and typically presents with unilateral atrophy of the musculature of the tongue and contralateral tongue deviation. Often, patients with HNP also report occipital/neck pain. A 75-year-old man with occipital/neck pain as a primary complaint. Although difficult to observe because of the filtering facepiece two mask, difficulties in articulation and sialorrhea during the interview were noticed. These latter were cues to consider CN examination that revealed CN XII palsy. This prompted a referral for further examination that revealed an SC compressing the right hypoglossal canal. The patient was not considered a surgical candidate and was managed conservatively. This case report outlines the relevant findings relating to the triage of a rare isolated hypoglossal nerve palsy from the physiotherapist's perspective within a complex setting because of the COVID-19 pandemic. Although referred with a diagnosis of cervical radiculopathy, our case highlights that skilled physiotherapists may play a fundamental role in both the recognition and, when applicable, subsequent novel management of a non-musculoskeletal presentation.

Response to the Letter to the Editor-in-Chief.

Author response to the JOSPT Letter to the Editor-in-Chief "A Second Look at the Risks of Serious Adverse Events with Orthopaedic Manual Therapy, Paracetamol, and NSAID Treatment of Neck Pain" J Orthop Sports Phys Ther 2023;53(6):1-2. doi:10.2519/jospt.2023.0202-R.

Implementation of the International IFOMPT Cervical Framework: A survey among educational programmes.

BACKGROUND: Orthopaedic Manual Therapy (OMT) is a specialized area of physiotherapy for the management of neuromusculoskeletal conditions. Although rare, adverse events after OMT are reported in literature. In 2020, the International Framework for Examination of the Cervical Region for potential of vascular pathologies of the neck prior to OMT Intervention was presented. OBJECTIVE: To evaluate the knowledge and implementation status of OMT educational programmes regarding the 2020 International IFOMPT Cervical Framework. METHODS: An international survey with closed- and open-ended questions was conducted among all IFOMPT educational programmes using an online survey. Formal informed consent was requested at the beginning of the survey and all data were collected anonymously. RESULTS: Thirty-nine educational programmes filled in the survey. Twenty-four programmes (61.5%) had already implemented the new Framework. Four programmes (10.3%) answered that they will not implement the new Framework in their educational programme. Positional testing will be kept in about 54% of the programmes. Craniovertebral ligament testing will be kept in about 90% of the programmes. A considerable number of educational programmes still teach end range manipulations in the middle and lower cervical spine (33.3%) and upper cervical spine (25.5%). CONCLUSIONS: The dissemination and implementation of the International IFOMPT Cervical Framework among educational programmes has been successful. However, although positional testing and craniovertebral ligament testing are excluded from the Framework, most educational programmes will keep these tests in their curriculum, which raises some concern regarding the success and impact of international consensus frameworks.

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.

A guide to cranial nerve testing for musculoskeletal clinicians.

BACKGROUND: Neurological examination in musculoskeletal practice is a key element of safe and appropriate orthopedic clinical practice. With physiotherapists currently positioning themselves as advanced first line practitioners, it is essential that those who treat patients who present with neck/head/orofacial pain and associated symptoms, should have an index of suspicion of cranial nerve (CN) dysfunction. They should be able to examine and determine if CN dysfunction is present, and make appropriate clinical decisions based upon those findings. METHODS: This paper summarizes the functions, potential impairments of the nerves, associated conditions, and basic skills involved in cranial nerve examination. RESULTS: A summary of cranial nerve examination is provided, which is based on the function of the nerves, This is intended to facilitate clinicians to feel more confident at understanding neural function/impairment, as well as performing and interpreting the examination. CONCLUSION: This paper illustrates that CN testing can be performed quickly, efficiently and without the need for complicated or potentially unavailable equipment. An understanding of the CN's function and potential reasons for impairment is likely to increase the frequency of CN testing in orthopedic clinical practice and referral if positive findings are encountered.

Identifying vascular pathologies or flow limitations: Important aspects in the clinical reasoning process.

Cervical spine manipulation and mobilisation are frequently used in the management of neck pain and headache. Although very rare, serious adverse events (SAEs) following cervical spine manipulation and mobilisation have been described. Recently, a revised version of the International IFOMPT Cervical Framework was published, to provide guidance for the assessment of the cervical spine region for potential vascular pathologies of the neck in advance of planned Orthopaedic Manual Physical Therapy (OMPT) interventions. Clinicians should realise that following the Framework does not guarantee that vascular pathologies or flow limitations will be identified. To illustrate this, in this Professional Issue, we use a case description of a SAE that occurred in the Netherlands during a mobilisation technique used by a physiotherapist and discuss this case using the IFOMPT Cervical Framework and highlight some important aspects in the clinical reasoning process.

Assessing Vascular Function in Patients With Neck Pain, Headache, and/or Orofacial Pain: Part of the Job Description of All Physical Therapists.

SYNOPSIS: Vascular serious adverse events can occur after examining, manipulating, mobilizing, and prescribing exercise for the cervical spine. Patients presenting with neck pain and headache who develop a vascular serious adverse event during or after treatment may have vascular flow limitations that go unrecognized and are aggravated by treatment. Patients with neck pain and headache-the first nonischemic symptoms of arterial dissection-frequently access physical therapists as first-point providers, not all of whom have specialist training in orthopaedic manual physical therapy. All physical therapists, irrespective of their training, who are helping patients manage neck pain, headache, and/or facial symptoms must feel confident to identify potential vascular flow limitations of the neck prior to providing treatment. J Orthop Sports Phys Ther 2021;51(9):418-421. Epub 10 May 2021. doi:10.2519/jospt.2021.10408.

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.