Interpretation of key points of International Framework for Examination of the Cervical Region for potential of vascular pathologies of the neck prior to Orthopaedic Manual Therapy (OMT) Intervention: International IFOMPT Cervical Framework

doi:10.12307/2023.922

Abstract

Abstract: BACKGROUND: The evaluation and management of cervical vascular pathologies before orthopedic manual therapy have great significance for reducing risks, ensuring patients’ interests and promoting optimal clinical decision-making. However, the research and exploration of this field in China are still in its infancy. In 2020, the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) released the International Framework for Examination of the Cervical Region for potential of vascular pathologies of the neck prior to Orthopaedic Manual Therapy (OMT) Intervention: International IFOMPT Cervical Framework (2020). This framework has important references and guiding values for the clinical practice of cervical manipulation in China.
OBJECTIVE: To integrate and interpret the core content of the framework, to provide a reference for the clinical practice of cervical manual therapy in China.
METHODS: On the basis of a full study of the framework, the authors interpret the core content of the framework from eight aspects including clinical reasoning, patient history, planning the physical examination, physical examination, risk and benefit. Meanwhile, seven databases including PubMed, EMbase, Cochrane Library, CNKI, WanFang, VIP and China Biomedical Literature Service System databases were searched by computer to screen clinical practice guidelines and expert consensus on neck pain. Through longitudinal comparison of multiple high-quality guidelines and consensus, the authors combine with the clinical practice in China to carry out discussion and analysis.
RESULTS AND CONCLUSION: This framework expounds the management strategy and implementation path of cervical vascular disease evaluation before cervical manipulation from multiple dimensions, suggesting that we should improve clinicians’ attention to cervical vascular disease evaluation before manipulation, and construct evaluation criteria and implementation path with Chinese clinical characteristics. Meanwhile, we should further carry out basic scientific research with multidisciplinary techniques and promote shared decision-making and teaching model innovation to achieve the best clinical decision.

Key words: cervical manipulation, neck pain, vascular disease, international framework, International Federation of Orthopaedic Manipulative Physical Therapists, interpretation of key points

CLC Number:

Feng Tianxiao, Bu Hanmei, Wang Xu, Zhu Liguo, Wei Xu. Interpretation of key points of International Framework for Examination of the Cervical Region for potential of vascular pathologies of the neck prior to Orthopaedic Manual Therapy (OMT) Intervention: International IFOMPT Cervical Framework[J]. Chinese Journal of Tissue Engineering Research, 2024, 28(9): 1420-1425.

Figures/Tables 7

2.2.3 计划体格检查《IFOMPT 2020》强调计划体格检查的必要性。物理治疗师通过分析病史中的临床数据形成主要的颈部血管疾病假设，并在体格检查中不断检验假设是临床推断的必要环节，是临床决策的基础条件。因此，物理治疗师需要详细地计划进行体格检查。物理治疗师也需要评估是否需要进一步获取患者的临床数据，所获取的信息是否存在缺陷以及临床数据质量是否足够。基于对患者病史数据的评估和分析，物理治疗师在此环节需要考虑：①OMT操作的注意事项；②OMT操作的禁忌证；③考虑到体格检查相关的风险因素，在体格检查中需要进行哪些项目以及需要排除哪些项目；④优先进行哪些体格检查项目；⑤这些体格检查是否适合患者。 2.2.4 体格检查体格检查的目的旨在继续检验物理治疗师采集病史阶段产生的血管相关疾病假设，以决定是否需要医疗转诊或进行OMT干预。《IFOMPT 2020》和《IFOMPT 2012》相比主要差异在于前者删除了位置觉检查(positional testing)和颅颈韧带检查(craniovertebral ligament testing)，更详细地描述血压、神经系统检查和颈动脉检查的重要性。《IFOMPT 2020》推荐的体格检查方法如下：①血压：血压测量可用以评估脑卒中的风险，特别是来源于颈动脉的风险，血压测量也可以评估急性动脉损伤风险如颈动脉和椎动脉；②神经系统检查：检查周围神经和颅神经以评估上运动神经元病变时的表现，将有助于评估神经血管疾病存在的可能性；③颈动脉检查：由于颈动脉的解剖位置相对表浅，物理治疗师可进行颈总动脉和颈内动脉的触诊和听诊。如双侧颈内动脉搏动不对称可能是颈内动脉疾病的重要特征，触诊到搏动性、可扩张的肿块常提示颈动脉瘤可能。听诊存在杂音常提示颈动脉瘤、颈动脉夹层和颈动脉狭窄等疾病可能。 2.2.5 风险与效益 (1)风险：由于OMT相关严重不良事件的发生率较低，现有临床数据难以支撑探究其风险与效益关系。临床诊疗过程中患者的症状和体征不同，已知的危险因素多样，这要求物理治疗师做到个体化评估患者的风险是否会增加并将风险降至最低。《IFOMPT 2020》指出物理治疗师需要考虑的风险主要包括两方面，即现有血管疾病的误诊风险和OMT后发生严重不良事件的风险。研究发现在一般人群中，椎动脉夹层发生率为(0.75-2.90)/10万[21-22]，颈内动脉夹层发生率为椎动脉夹层的3-5倍[23-24]。绝大多数OMT导致的严重不良事件是由椎动脉受累所致，现有研究表明与OMT相关的椎动脉夹层发生率为(0.4-5.0)/10万[25]，因此在OMT干预前需要进行合理的风险评估流程[26]，见图5。同时，该标准总结了颈痛和头痛患者常用干预措施的风险，见表4。"

《IFOMPT 2020》建议物理治疗师在共享决策过程结束后获取患者知情同意。知情同意指患者在充分了解治疗或研究程序的性质、目的和影响基础上，自愿同意参与治疗或研究程序的可撤销的协议[28]。知情同意的过程主要包括知情同意的类型、物理治疗师提供信息的要求、获取信息的方式以及知情同意过程记录的要求。知情同意的类型包括明示同意和默示同意。明示同意是患者以书面或口头方式给予明确同意的类型。默示同意则是由物理治疗师根据患者的行为或缺乏某些行为暗示同意。《IFOMPT 2020》强调无论是哪种知情同意类型，患者在治疗期间都可以随时撤回，不应受物理治疗师影响。对于获取知情同意的时间，该标准指出物理治疗师应在治疗前取得知情同意，治疗过程中征取患者知情同意将不利于决策。对于治疗过程中治疗方案的改变，物理治疗师必须进行完整的知情同意程序，并以口头或书面形式明确获得同意。若继续进行相同的治疗方案，建议物理治疗师充分考虑患者的意愿，在多数情况下，患者口头同意继续使用干预措施即可。对于知情同意书的记录，建议物理治疗师对公开信息、知情同意的获取以及双方的讨论内容进行简要说明，建议每次治疗时均如实记录知情同意的获取情况。《IFOMPT 2020》是面向国际范围推广的标准，由于各地法律和卫生条例对知情同意的要求不同，并且考虑到患者病情和干预措施的特异性，该标准未提供标准化的表格和模板。 2.2.7 安全的OMT实践《IFOMPT 2020》指出物理治疗师在选择和应用颈部OMT时应合理地考虑以下因素以保证颈部OMT的安全实践：①应用低振幅、短杠杆的推力即运用最小力量施加到颈椎的内部结构；②患者的安全和舒适是物理治疗师进行检查和选择治疗技术的基础，应充分尊重患者的偏好和价值观；③在颈椎生理活动范围的极限应谨慎使用检查和治疗技术，尤其是颈椎后伸和旋转，以免对颈部动脉和神经结构造成压迫；④鼓励患者采取仰卧位，一方面物理治疗师通过观察和沟通能够及时接收到反馈，另一方面此体位能够使患者感到舒适；⑤在操作前使患者在预置体位，以评估患者的舒适度和任何不适或意外的反应；⑥治疗频率根据患者病情及个人情况而定，建议联合使用颈椎手法、健康教育、运动疗法等多模式方法治疗颈痛和头痛；⑦应持续监测患者对颈部OMT的反应和不良事件的发生情况；⑧物理治疗师应合理地进行自我评估即是否具备安全有效地完成颈部OMT操作的能力。若临床技能有限，应推荐给在颈部OMT操作方面具有一定资质或已经过专业培训的物理治疗师；⑨在发生严重不良事件时，物理治疗师应迅速采取科学、有效的应急管理措施，必要时联系急救服务或进行心肺复苏。 2.2.8 颈部OMT教学《IFOMPT 2020》从谁来教、教什么、如何教3个维度提供了建议。首先，颈部OMT的教育者应具备如下资质：①积极参与专业领域内的临床实践；②具有丰富的教学经验，最好包括在成人教育方面的指导或培训；③在临床实践和教学中应用循证医学的概念；④接受过颈椎手法的教学和运动心理方面的培训，经过权威机构或专业组织正式认证；⑤具有充足的神经肌肉骨骼相关疾病的体格检查、鉴别诊断和临床推断能力；⑥定期进行有关颈椎手法的专业学习和培训，并随时掌握最新的研究证据。对于教学内容，《IFOMPT 2020》指出手法教学需要符合最佳临床实践，注重手法安全实践，强调手法操作的振幅、速率、患者的舒适度、操作的敏感性和特异性，学生应在教师的指导下逐步锻炼手法的灵巧性和操作技能。对于如何教学方面，《IFOMPT 2020》指出虽然学生间手法练习是常用教学方式，但要强调安全操作，教师需要在学生练习前和练习过程中需要持续评估和检测风险因素和学生反应，让学生以适当方式锻炼手法的灵巧性，并尊重学生的自主选择，在任何时候均可以寻求教师的帮助。"

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