Integrated Musculoskeletal Teams

Musculoskeletal medicine has undergone a considerable change since the Department of Health released the musculoskeletal services framework in 2006.  Clinical musculoskeletal teams in the UK have moved away from the familiar physician-led model and the use of extended scope practitioners is now widely accepted as best practice. Musculoskeletal teams mostly consist of extended scope practitioner physiotherapists although, in some NHS trusts and MSK partnerships, other allied health professionals such as podiatrists, osteopaths and occupational therapists work alongside physiotherapists in multidisciplinary musculoskeletal teams.

I am currently writing an initial scoping document aimed at assessing the current makeup of musculoskeletal teams and looking at any quality, efficiency and productivity improvements that can be made by making musculoskeletal teams truly multidisciplinary.  I am very interested in hearing the opinions of musculoskeletal physicians, nurses, clinicians, and allied health professionals working in musculoskeletal multidisciplinary teams or those that are interested in doing so.  I also welcome comments from patients, professional bodies and healthcare regulators.

It could be argued that the clinical role of an extended scope practitioner is predetermined by the position in the care pathway that the extended scope practitioner is working in (usually between the patient’s general practitioner/physiotherapist and secondary care consultants).  My question and interest relates to whether non-physiotherapist clinicians can work as extended scope practitioners rather than should we be integrating osteopathy, podiatry or occupational therapy (as examples) within musculoskeletal NHS teams – the efficacy of which is a different topic entirely.

As a guide, I’m interested in comments from potential and existing extended scope practitioners or from physicians that work alongside non-medical clinicians in this field.  I am interested in what training issues there might be, what governance arrangements might be necessary and particularly any potential conflicts that you might foresee.

Having worked in multidisciplinary teams for the vast majority of my 20 year NHS career I can only see advantages but I have benefited from supportive, forward-thinking employers and colleagues that have patient management as a core value.  I appreciate, however, that working in a multidisciplinary team might pose a number of questions and it is this that I am trying to explore in this scoping exercise.

Please feel free to comment below or use the contact page should you wish to discuss this privately.  I am happy for comments to be anonymous but will moderate out abusive comments et cetera.

 

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Safety of manual therapy and manipulation

Introduction
Patients presenting with musculoskeletal symptoms might be offered manual therapy or spinal manipulation as part of a treatment plan or in isolation. The use of manual therapy and spinal manipulation is therefore frequent and the purpose of this essay is to ensure patient safety and the correct use of this specific treatment modality. Whilst manual therapy is considered patient-centred, it remains a passive form of physical therapy where the therapist applies the treatment to the patient.

Broadly, manual therapy is a method of treatment that is commonly used by musculoskeletal physicians, osteopaths, physiotherapists and chiropractors. It aims to quickly reduce pain and improve movement (1) and is clinically and cost-effective (2). Manual therapy treatment can include techniques that glide joints in a rhythmic manner (mobilisation), gap joint surfaces (manipulation) and/or use muscle contractions to restrict or loosen joints. Manual therapy rapidly reduces pain and muscle spasm and allows help with movement. Additionally, manual therapy can help exercise muscles that are not working due to pain – this can help with exercises (3).

Manual therapy is effective in treating neck and back pain and is recommended in national and international treatment guidelines (4). The majority of patients with spinal pain can expect to see a reduction in pain and improvement in function following a course of manual therapy.

The commonest adverse reaction to manual therapy is treatment soreness, which can last a day or two (5, 15). This is a normal, temporary response to having a stiff area of the spine stretched or weak muscles exercised.
Spinal manipulation techniques involve gapping joint surfaces to effectively reduce joint stiffness, muscle spasm and pain (1). There are very rare cases of patients having serious adverse events, including stroke and death, following these techniques (6). These events are associated with damage to the arteries running through the neck. The ‘average’ risk of such events is estimated to be approximately 1 in 2.5 million treatments. (12)

Objectives
This essay is aimed at providing clinical guidelines for the use of manual therapy and spinal manipulation by physicians and clinicians that perform manual therapy and spinal manipulation. The purpose of which is to reduce the risks of adverse reactions and clinical complications.

Definitions
Manual therapy: a general term including hands-on techniques that glide joints in a rhythmic manner (mobilisation), gap joint surfaces (manipulation) and/or use muscle contractions to restrict or loosen joints.

Joint mobilisation: movement up to, but within, normal physiological ranges of joint mobility.

Spinal manipulation: gapping joint surfaces to effectively reduce joint stiffness, muscle spasm and pain.

In practice there is often a ‘grey area’ where joint mobilisation tapers into spinal manipulation. These guidelines are not specifically directed towards spinal manipulation and they should be equally borne in mind for all joint mobilisation techniques. Therefore, these guidelines apply to all forms of manual therapy, and safety depends not just upon good manual technique but also a satisfactory history and musculoskeletal assessment before proceeding to therapeutic procedures of any kind.

It is important to clarify the use of the term “spinal manipulation” in comparison to “joint mobilisation”. Whilst both terms are often used in conjunction when describing manual therapy in general, spinal manipulation’s precise medical usage describes the facilitation of movement beyond normal physiological but within anatomical ranges. This distinction as a therapeutic modality must be clearly documented in clinical records.

Development & evidence base
The evidence base for this guideline has been described in the Introduction. As further evidence emerges for the use of manual therapy and spinal manipulation and the contraindications thereof, clinical guidelines will be updated. Ongoing research into the safety of cervical spine manipulation (13) is likely to impact upon this guideline and it will remain the author’s responsibility to inform the clinical team should any changes in practice need to occur.

Guidance
All patients must have a clinical assessment of their presenting complaint prior to undertaking manual therapy/spinal manipulation, which will include a full case history and physical assessment. Should diagnostic imaging or tests be necessary, all results should be obtained prior to deciding upon the employment of manual therapy or spinal manipulation.

At the first treatment an explanation of the procedure and its possible adverse effects should be given to the patient.

Patients should be asked to give their verbal consent before the first treatment. A record that this information has been imparted and the patient has consented should be recorded in the notes.

Formal written consent is not mandatory (with the exception of persons under 16 in the UK, in which case a parent or carer should be present during the consent process and sign the consent form). This consent form should be signed by the patient and the practitioner and one copy filed in the clinical case notes.

Contraindications to treatment
Whilst spinal manipulation and mobilization remains an extremely safe form of treatment, a number of contraindications to treatment exist and must be adhered to.

Absolute contraindications to treatment
• Where it is more likely that the risks of spinal manipulation will outweigh the potential benefits: –
• Bone disease – tumours, metastases, infection, fractures, bone weakness (long term steroids/osteomalacia, severe osteoporosis), severe inflammatory types of arthritis (not osteoarthritis).
• Neurological considerations – spinal cord compression, moderate to severe nerve root compression from a disc/spondylolisthesis, myeloradiculopathy.
• Rheumatological considerations – active rheumatoid arthritis, ankylosing spondylitis and polymyalgia rheumatica are all contraindications. The last is particularly important as to use manipulation may delay the prescription of steroids and thus risk retinal artery thrombosis and blindness.
• Vascular considerations – the risk of the patient having an aortic aneurysm, severe coagulation deficiencies, severe vertebro-basilar insufficiency (see below), ischemic cervical and thoracic myelopathy must be considered and ruled out where possible. The vascular supply to the spinal cord is only just adequate. A spinal cord already ischaemic should not have manipulative techniques inflicted upon it.
• Lack of clinical hypothesis – where the exact cause of the pain is unclear and there is no obvious mechanism of injury, spinal manipulation should not be used.
• Issues of consent or co-operation – where the patient is unable to clearly understand the aims of treatment, is unable to give their informed consent or where the patient is unable to co-operate with treatment.
• Hypermobility that is severe enough to produce frank instability – lax ligament syndromes/spondylolisthesis. The rheumatoid neck must never be manipulated as life could be at risk by the posterior dislocation of the odontoid process through a weakened or ruptured transverse ligament. Grisels syndrome (1) has been demonstrated radiologically that in children with upper respiratory tract infections there may be hypermobility of the upper cervical spine.

Relative contraindications
• Where it is less clear whether the risks of spinal manipulation will outweigh the potential benefits.
• Adverse reactions to similar treatments in the past.
• Intervertebral disc prolapse – where there has been shown to be a prolapse that is large enough to be causing frank neurological compression.
• Pregnancy – Spinal manipulation and its risks need to be discussed in relation to precipitating a miscarriage (in the first trimester) or premature labour (in the last trimester). The overall risks are low during the second trimester where gentle techniques are advised. (14)
• Osteopenia, osteoporosis, metabolic bone disease
• Hypermobility syndromes with ligamentous laxity. If all movements on pre-manipulative positioning of the patient are painful, manipulation should not be attempted
• Psychological dependence upon manipulative treatment.

Vertebro-Basilar Arterial insufficiency
Episodes of vertebro-basilar arterial insufficiency have been reported to be provoked by manipulation of the cervical spine. The anatomy of the vertebral artery is such that rotation of the upper cervical spine of 30 degrees or more might cause a diminution and even an interruption of the blood flow of the vertebro-basilar artery opposite to the direction of the rotation which may lead to a fatality, although recent evidence suggests the contrary. (16)

The key to the prevention of these problems is in the taking of a careful clinical history. Any symptom such as vertigo, giddiness on turning suddenly or standing up, of loss of consciousness or transient hemiparesis must be carefully elicited and all further neck rotation avoided, (12, 13).

Given a normal history it is reasonable to proceed with the examination having warned the patient to report any giddiness or other relevant symptom and to desist immediately if this happens.

Post treatment management
Risk of minor and moderate adverse events to manual therapy/spinal manipulation is high (circa 50%) but the effects are mild and short lived (15). Patients should be encouraged to contact their clinician should any adverse event last longer than 72 hours. Post treatment, patients may feel sleepy, light-headed, or experience some aching in the areas in which treatment has been directed. Should symptoms progress acutely, medical attention should be sought immediately.

Management of musculoskeletal ‘red flags’
Patients presenting with symptoms suggestive of cauda equina symptoms, muscle weakness or any conditions referred to in 9.1 should not be treated using manual therapy or spinal manipulation and must be managed in a clinically relevant way.

References
1. Herzog W. (2010) The Biomechanics of Spinal Manipulation. Journal of Bodyworks and
Movement Therapies. 14:280-286.

2. Michaleff A.Z., Lin C.-W.C.,Maher C.G., van Tulder M.W. (2012) Spinal Manipulation
Epidemiology: Systematic Review of Cost-Effectiveness Studies. Journal of Electromyography and Kinesiology. 22:655-662.

3. Haavik H., Murphy B. (2012) The role of spinal manipulation in addressing disordered sensorimotor integration and altered motor control. Journal of Electromyography and Kinesiology. 22:768-77.

4. Carragee E.J, van der Velde, et al., Carroll L.J. et al., (2009) Treatment Of Neck Pain: Noninvasive Interventions. Results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Journal of Manipulative and Physiological Therapeutics. 32:S141-S175.

5. Carnes D., Thomas S, Mars T.S., Mullinger B., Froud R, Underwood M. (2010) Adverse events and manual therapy: A systematic review. Manual Therapy.15: 355–363.

6. Miley M.L., Wellik K.E., Wingerchuk D.M., Demaerschalk B.M. (2008) Does Cervical Manipulative Therapy Cause Vertebral Artery Dissection and Stroke? The Neurologist. 14:1, 66-73.

7. Cassidy J.D., Boyle E., Côté P., He Y., Hogg-Johnson S., Silver F.L., Bondy S.L.(2008) Risk of Vertebrobasilar Stroke and Chiropractic Care. Results of a Population-Based Case-Control and Case-Crossover Study. Spine. 33:4S. S176-S183.

8. Kerry R., Taylor A.J., Mitchell J., McCarthy C., Brew, J. (2008) Manual Therapy and Cervical Arterial Dysfunction, Directions for the Future.

9. Grisel (1930) Enucleation de l’atlas et torticollis nasopharyngien. Presse Med 38,50.

10. Cyriax (1982) Textbook of Orthopaedic Medicine.

11. Ernst and Cantor (2006) A Systematic Review of Spinal Manipulation. JR Soc. Med. 99:279-280

12. Ernst E. (2010) Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract;64:673-7

13. Taylor, Alan J. et al. (2010)
A ‘system based’ approach to risk assessment of the cervical spine prior to manual therapy
International Journal of Osteopathic Medicine , Volume 13 , Issue 3 , 85 – 93

14. Stuber, Kent Jason et al (2012)
Adverse events from spinal manipulation in the pregnant and postpartum periods: a critical review of the literature
Chiropr Man Therap. 2012; 20: 8.

15. Carnes, Dawn et al (2009)
Adverse events in manual therapy: a systematic review
National Council for Osteopathic Research

16. Erhardt, Jonathan et al (2015)
The immediate effect of atlanto-axial high velocity thrust techniques on blood flow in the vertebral artery: A randomized controlled trial
Manual Therapy Vol. 20 Iss. 1, February 2015

Myofascial Trigger Point Therapy

A trigger point (1) is described as ‘a focus of hyperirritability in a tissue that, when compressed, is locally tender and, if sufficiently hypersensitive, gives rise to referred pain and tenderness’. The most commonly reported trigger points are sited in the muscles of the shoulder region (trapezius muscle) and the lower back (quadratus lumborum muscle) (1).

Treatment requires the ‘deactivation’ of the trigger point (TrP) and this may be achieved in a number of ways. A manual method for deactivation of trigger points involves the application of firm digital pressure which may be a combination of alternating pressure and release for up to 2 minutes. The pressure is thought to create a local ischemia which inhibits the neural activity maintaining the reflex, causing the associated taut band to release (2). Alternatively, muscles can also be released by inserting very fine (e.g. 0.25mm diameter) needles into the TrP which may help in relieving symptoms.

1. Travell JG, Simons DG. Myofascial pain and dysfunction: the trigger point manual, vol 2. Baltimore: Williams and Wilkins; 1992

2. Parsons, J. and Marcer, N. Osteopathy—Models for diagnosis, treatment and practice, Elsevier, Churchill Livingstone; 2005

Social Media

It took me a while and, like always, I was a little nervous and unfasionably late to the party but I’ve slowly grown fond of social media but particularly Twitter.  Even though this website stumbles through time with very limited attention, I still feel that I should drive a bit of a wedge between what is published on this site and my twitter feed.  This website will be totally work related – the day job, as it were. Twitter will be something entirely different.

For me, twitter has been summed up brilliantly by Dr. Ben Goldacre;

‘I just think everyone, no matter who they are or what they do, is entitled to fart about on twitter.’

So – website is work, twitter is my social outlet. Some of my tweets will be work related, some will be me moaning about the man opposite me on the train that is snoring too loudly. I may use twitter to pass on some interesting health-related information – but please remember, retweeting does not always mean agreement.

Osteopathy

In 2008, I originally posted this article shamelessly plagiarising an essay by Samuel Homola entitled ‘What a Rational Chiropractor Can Do for You’.

In view of the differences between osteopaths and chiropractors in America I felt that it seemed appropriate for me to anglicise Homala’s piece.

I can take absolutely no credit for what follows but have re-posted it on this site primarily because the text continues to sum up my own feelings about osteopathy, perfectly.

I added a small amount of text and removed some non-osteopathic references. Furthermore, I contacted Samuel Homola and asked his permission to reproduce his essay and invited him to comment which, as you will see after the article, he did.

‘What an osteopath can do for you…’

Spinal manipulation can relieve some types of back and neck pain and other conditions related to tightness and loss of mobility, such as tension headache or aching in muscles and joints. It is also considered that massage may be as effective as cervical manipulation in relieving tension headaches. However, physical therapy techniques may be as effective as spinal manipulation in long-term relief of back pain. Osteopaths can offer all of these modalities, when appropriate, and thus provide patients with a choice. They may also offer basic advice about nutrition, weight loss, exercise, ergonomics, relaxation techniques, body mechanics, home care (such as use of hot or cold packs), massage, and other self-help measures that might help relieve or prevent aches and pains.

Science-based osteopaths make appropriate judgments about the nature of their patients’ problems, determine whether these problems lie within their scope, and make appropriate referrals for problems that do not. Osteopaths who use manipulation and physical therapy appropriately are also willing to coordinate with your doctor so you can therefore benefit from the best that both have to offer.

Making a hypothesis

While some types of back pain can benefit from spinal manipulation, not every patient who sees an osteopath needs it. Proper investigation and examination should precede treatment of any type. This is why, if you consult an osteopath, it is crucial to choose one who can make an appropriate hypothesis, uses spinal manipulation only when indicated, does not order unnecessary x-rays, and refers to an appropriate physician when needed.

Back-pain sufferers who have been diagnosed with musculoskeletal pain and have reservations about spinal manipulation should ask their doctor whether a referral for physical therapy is appropriate for their condition. A study published in 1998 in The New England Journal of Medicine found that the long-term effectiveness of spinal manipulation was no better than the McKenzie method of physical therapy (an exercise program) [1].

Manipulation vs. Mobilisation

Manipulation and mobilisation are used primarily in the treatment of conditions related to mechanical-type problems in joints and muscles.

Manipulation is a hands-on procedure used to restore normal movement by loosening joints and stretching tight muscles. In some cases, manipulation will restore normal movement by ‘unlocking’ a joint. A popping sound often occurs when a spinal joint is stretched a little beyond its normal range of motion.

Mobilisation simply stretches soft tissues by moving joints through a full range of movement. Mobilisation can increase the range of motion of the arms, legs, and shoulders, but manipulation may be more effective in relieving pain and restoring normal movement in the spinal joints.
Any portion of the spine that is tight, stiff, or painful on movement might benefit from appropriate manipulation. Different methods are used in different portions of the spine, since joint structure and the direction of movement in the neck and upper back differ from those of the lower back. For example, neck manipulation and upper-back manipulation might be done while the patient lies on their back whilst lower-back manipulation might be done while the patient lies on one side. Dozens of manipulative techniques can be used to meet the special needs of patients who must be positioned one way or another.

Neck Manipulation

Manipulation may improve the mobility of a cervical spine that has been stiffened by osteoarthritis or by scar tissue from an old injury. Disc degeneration caused by wear and tear or by injury is a common cause of loss of range of motion in the cervical spine and can often benefit from manipulation. Neck manipulation or mobilisation may improve range of motion and provide relief for neck pain and muscle-tension headache. But remember that benefit must be weighed against risk. Neck manipulation should not be used unless symptoms indicate a specific need for it. It should be done gently with care to avoid excessive rotation that could damage the patient’s vertebral artery. Neck manipulation should not be done immediately after an injury that causes acute neck pain. When the acute pain subsides, usually after a few days, manipulation may be useful to relieve restriction and restore normal joint mobility. Once the patient is symptom-free, it should be discontinued.
Patients who have pain caused by acute inflammation, as in rheumatoid arthritis or spondylitis, will rarely benefit from neck manipulation. Damage to upper cervical connective tissues in rheumatoid arthritis can also be a contraindication. When in doubt about whether you should undergo neck manipulation, check with your doctor and osteopath. A competent osteopath should not object to your seeing a specialist for a second opinion, in fact, they might actively encourage it.

Tension headaches, often called muscle-contraction or cervicogenic headaches, may benefit from manipulation that loosens joints and stretches tight neck muscles. Some anecdotal case reports suggest that migraine headache can be relieved with cervical manipulation. However, true migraine is unlikely to be relieved by neck manipulation.

Any kind of persistent headache should be brought to the attention of your family doctor whom may refer you to a neurologist. And so should any headache accompanied by fever, vomiting, weakness, a change in speech or vision, or any other unexplained symptoms. Severe headaches may require medical attention for pain relief.

Before submitting to cervical manipulation for the treatment of headache, it is essential to determine whether the problem might be caused by other factors and this is why it is important you’re your osteopath and doctor are aware of your symptoms. Fortunately, most headaches are of the simple tension or muscle-contraction variety. So there is a good chance that simple mobilisation or stretching of neck will relieve them.

A study published in 1998 in the Journal of the American Medical Association found that cervical manipulation might be no more effective than massage in the treatment of episodic or recurring tension headache [2]. Thus people with frequent tension headaches might want to first try mobilisation rather than cervical manipulation.

Thorax and Low Back

Pain in the upper and lower portions of the spine can often be treated successfully with manipulation and physical therapy. Low back pain is more common, is usually more serious, and deserves more attention. Herniated discs are rarely a problem in the upper back or thoracic spine, for example, while a herniated disc in the lower back or lumbar spine can pinch spinal nerves and cause weakness and loss of sensation in the legs or encroach upon the spinal canal to impair bladder or bowel function (this is referred to as cauda equina syndrome). This is why the Agency for Health Care Policy and Research (AHCPR) guidelines for treating low back pain caution against manipulating the lumbar spine when there is leg pain caused by nerve-root involvement [3].

Except when the thoracic vertebrae have been softened by disease or by aging, appropriate thoracic spine manipulation is rarely harmful and often can relieve backache related to fatigue, postural strain, arthritis, myofacitis, or other problems involving muscles and joints.

Other Joints and Muscles

Uncomplicated mechanical-type problems of the muscles or joints of the shoulder, elbow, wrist, knee, ankle, and foot can often be helped by an osteopath who uses physical therapy. Most osteopaths learn manipulative techniques for treatment of extremity joints, but these joints often benefit as much from mobilization as from manipulation.

Severe or prolonged problems with extremity joints should always be brought to the attention of a doctor. As with back pain, diagnosis is essential. When a condition under osteopathic care has not improved after three to six weeks, a specialist should be consulted for a second opinion. On the other hand, there are many situations where home care can be effective once the diagnosis has been made and acute symptoms have subsided. An osteopath will be able to advise when cost-saving self-care can be substituted for clinical, outpatient treatment. It is rarely necessary to continue any form of osteopathic treatment month after month.

References

1. Cherkin DC and others. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. New England Journal of Medicine 339:1021-1029, 1998.
2. Bove G, Nilsson N. Spinal manipulation in the treatment of episodic tension-type headache: A randomized controlled trial. JAMA 280:1576-1579, 1998.
3. Bigos S and others. Acute Low Back Problems in Adults. Rockville, MD: Agency for Health Care Policy and Research, 1994. AHCPR publication 95-0642.

Samuel Homola on July 15, 2008 at 1:26 pm said:

Jonathan,

I have no problem with your use of my article in equating musculoskeletal osteopathy with rational chiropractic.
I do not know anything about chiropractic in the UK. But since you are an osteopath, I do not see anything in your “plagiarized” version of the article that I would object to. Good luck.

Samuel Homola, D.C.