Translating the new International IFOMPT Cervical Framework into a framework flowchart for clinical practice and education

As with any patient’s health problem, a good interview is essential to assess the nature and severity of the presenting symptoms, and to determine whether the problem has the potential to respond to OMT or needs further referral. The physical therapist’s aim is to use the patient interview to make the best judgment on the probability of either the presence of serious pathology or contraindications to treatment, and to generate hypotheses.

Signs and symptoms of serious pathology (i.e., vascular pathology) should be recognized in the patient interview. During clinical reasoning, this can be ‘divided’ into (1) clear, (2) subtle or (3) no signs and symptoms of the suspected pathologies.

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Identification of clear signs and symptoms warrants a medical referral for further investigation. It is recommended that physical therapists refer for immediate medical investigation when their clinical suspicion is supported by the structured patient interview.

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Subtle signs and symptoms may require additional testing to support or refute the vascular hypothesis. Existing data support the use of conventional vascular examination [3] whereby the following tests are recommended [2]: blood pressure, cranial nerve examination and gait pattern. Having a high index of suspicion of vascular pathology may justify referral for further investigation. However, if a vasculogenic contribution is highly unexpected, the physical therapist may continue assessment and treatment according to the green pathway.

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In case of no relevant signs or symptoms of serious/vascular pathology, other information from the patient interview and the clinical examination, should confirm or reject the clinical suspicion of a musculoskeletal (MSK) disorder. If a non-MSK disorder is suspected, referral to other healthcare providers is warranted. For example, lightheadedness as one of the symptoms of hyperventilation, is not considered a red flag for physical therapy intervention but cannot be labelled as an MSK disorder. Therefore, referral to health care providers that are trained to treat this condition is indicated.

In addition, it is important to identify risk factorsindicating the potential for serious/vascular pathology. These risk factors should be ‘taken into account’ throughout the whole clinical reasoning process. This is indicated in the framework flowchart by the orange arrow starting from the patient interview to OMT intervention. Identification of risk factors may lead to additional testing or referral for further investigation. However, in case of a clear suspicion of a MSK disorder with no clear suspicion of a vascular hypothesis, these risk factors should be included in the risk & benefit analysis and used to determine the most suitable and safe OMT technique(s).

3.2 Clinical examination

Careful planning of the clinical examination is required to refine, re-rank or reject the hypotheses generated from the patient interview and to facilitate optimal clinical reasoning in OMT [4]. Clinical examination may consist of additional questions, or MSK examination and any additional testing to support or reject the vascular hypothesis. The physical therapist should define the type and order of testing with consideration of any risks and precautions associated with performing the tests.

3.3 Treatment

The decision to refer for further vascular diagnostic evaluation or proceed with physical therapy management needs to be made following the evaluation of the patient interview and clinical examination. If OMT intervention is indicated, and suspicion of underlying vascular pathology is refuted, the physical therapist weighs the anticipated risks all treatment modalities within the OMT intervention. This will be based on the clinical characteristics of the patient to the expected beneficial effects (risk and benefit analysis) to minimize the risk of complications. If the benefits outweigh the risks, appropriate OMT techniques should be applied.

Before proceeding to OMT intervention, individual practitioners will need to deliberate the treatment plan, adopt an approach to consent which includes sharing (verbal and written) information to the patient, explaining the expected treatment benefits, arguing alternative treatments and considering inherent risks associated with the patient’s presentation and the interventions that the practitioner is advocating. Additionally, the patient has to provide (verbal or written) informed consent. All this information needs to be reported in the (electronic) patient record. The therapist monitors response to treatment and any harmful incidents throughout treatment and progress in line with the clinical reasoning process.

4.1 Description of the case

4.2 Clinical reasoning

The first step is to recognize signs and symptoms of severe (vascular) pathology during the patient interview. In this case description, the sudden onset, high initial pain intensity (headache and neck pain), the restricted cervical rotation movement, nausea, ipsilateral headache, smoking history, hypertension, comorbid diabetes mellitus are signs and symptoms of the patient’s history that can be linked to potential vascular pathologies of the neck [2, 5].

However, at her first visit to the therapist who assessed the patient according to the IFOMPT Framework, no clear signs or symptoms of serious vascular pathology appeared to be present that needed referral to further investigation.

The next step is to assess the patient for both other subtle signs and symptoms, and risk factors for vascular pathology. As the patient complained of neck pain, ipsilateral headache, nausea, and lightheadedness, additional tests (neurological examination, coordination and gait, and blood pressure and auscultation) were indicated. Moreover, the patient interview highlighted the presence of hypertension, which is recognized as a risk factor for dissecting and non-dissecting stroke [2].

The additional testing as mentioned above did not reveal any abnormal findings, but the presence of subtle signs and symptoms and hypertension indicated that precaution is needed during the clinical examination, especially in older people [6, 7].

The next step is to define whether the signs and symptoms are related to a musculoskeletal disorder. If a non-MSK disorder is considered, the patient must be referred to other health care providers and should be excluded for further examination. If an MSK-disorder is suspected, a clinical diagnosis/hypothesis must be constructed based on the information from the interview.

Cervicogenic headache appears to be the most plausible hypothesis based on the symptoms experienced by the subject, i.e., neck pain, one-sided headache and restricted movement of the neck after a sudden onset (rotation of the neck) [8, 9]. As cervicogenic headache is defined as referred pain from the cervical spine to the head, the nociceptive drivers (articular joints, myofascial structures) of the pain should be identified during the MSK clinical examination [10, 11].

The clinical examination included inspection, movement examination, and articular and myofascial examination (including provocation and function tests) [12]. Motor control examination, including neuromuscular control (e.g. craniocervical flexion test [13], and evaluation of endurance/force (e.g. [14]) was not relevant at this time point due to the irritability of the current headache and neck pain. The order of testing was chosen carefully, the examination was carried out safely, and the therapist monitored the patient’s signs and symptoms during the examination. The clinical examination findings are shown in Table 1.

The results of the clinical examination guided further clinical reasoning and seemed to confirm the hypothesis of cervicogenic headache with an underlying cervical articular joint dysfunction and myofascial involvement. The signs and symptoms revealed during the patient interview (headache started after neck distorsion, a one sided and side-locked headache), the major loss of movement in rotation and extension, together with the painful C1-2 and C2-3 articular joints that provoked the familiar headache, the headache was finally classified as a cervicogenic headache.

As cervicogenic headache with an underlying articular joint dysfunction is considered as an indication for OMT intervention, the therapist must then weigh all included factors within a risk- benefit analysis and propose the most adequate and suitable treatment for this patient. In this scenario, the initial proposed treatment was education regarding pain and posture combined with passive high and low-velocity mobilizations of the cervical and thoracic spine, home-exercises and myofascial release techniques [15, 16, 17, 18]. According to the shared decision-making process, the therapist explained and discussed the indication, expected benefits, treatment options and potential risks with the patient. By giving the informed consent, the patient agreed to a multimodal treatment that included education, cervical and cervical-thoracic spine mobilization, and myofascial release techniques to reduce pain. Active midrange mobilization techniques were taught as home exercises.