Take 5 – IFOMPT Cervical Framework 

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By Dr. Nica Jacobson 

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

Take 5 – 5 Critical Takeaways to Improve Your Practice

  1. The five components of the clinical reasoning process include: taking a patient’s history, planning the physical exam, conducting the exam, planning the intervention, and evaluating the intervention. 
  2. There are many risk factors that are associated with an increased risk in a vascular event. 
  3. There is not one single test that will guide your clinical reasoning. 
  4. The risk of a vascular incident caused by therapeutic intervention is extremely low. 
  5. Shared clinical decision making is critical to planning your intervention. 

A 70 year old male comes into the ED with episodic neck pain and headache. He has a history of hypertension, CVA, and headaches that feel similar to this one. In the past, PT treated his neck pain. You are seeing him in the ED as their first point provider. What do you do? How do you know that this is truly musculoskeletal pain versus something more sinister? 

The study “International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention: International IFOMPT Cervical Framework ” describes in depth the framework for distinguishing vascular pathologies from musculoskeletal ones (1). Unlike a clinical prediction rule, this framework is not a “if this, then that” hard and fast rule. Instead, it provides guidance to use for clinical reasoning and to make sure that the provider has more knowledge and tools to use in their clinical reasoning. Other than taking a deep dive into the framework on your own, here are the most important takeaways for this journal article.

  1. The five components of the clinical reasoning process include: taking a patient’s history, planning the physical exam, conducting the exam, planning the intervention, and evaluating the intervention. 
    • Vascular pathologies may be identified if asking the right questions 

As a clinician, we know what clinical reasoning is. But what if there was a guided way to do it, especially for a very important aspect of differential diagnosis? This framework was built to provide that clarity and help you look for signs and symptoms and risk factors that could be or contribute to a vascular pathology.

The patient history may be one of the most important parts because several vascular pathologies can be identified by asking the right questions. When planning your exam, you must consider what specific tests are indicated in order to provoke possible signs and symptoms of a vascular cause. If you decide the relative risk is high, a referral is warranted. If risk is low and you believe the head and neck pain is musculoskeletal by nature, then planning the intervention with your patient weighing in is important. Finally, make sure you evaluate the intervention and ensure the patient knows how to follow up if new or changing symptoms arise. By performing these 5 steps, you can reduce the incidence of safety events from happening and provide better patient centered care. 

  1. There are many risk factors and clinical features that are associated with an increased risk in a vascular event. 

In the article, Tables 2-8 go into detail about what risk factors and symptoms are most common based on different types of vascular events (dissection, non-dissection, VBA dissection, ICA dissection). Some common ones include recent trauma, headache, neck pain, hypertension, smoking, ataxia, dysphasia/dysarthria/aphasia, weakness, dysphagia, ptosis, facial palsy, and visual disturbance. By developing clinical patterns to determine relative risk of an event occurring and categorizing clinical features while performing differential diagnosis, it allows you to be more informed in your clinical decision making. 

  1. There is not one single test that will guide your clinical reasoning. 

As stated in the article, positional testing cannot be utilized to rule out a vascular pathology. Similar to the points above, the framework collectively is used to guide your clinical reasoning and every decision you make is graded on relative risk. When clustered together, tests may be more impactful on your decision, but there will never be one test that informs your decision making. Taking a thorough patient history, performing an exam clinically relevant (including taking blood pressure, performing a neurologic exam, and assessing the carotid arteries when you are concerned about relative risk and/or vascular cause), and using shared decision making to plan intervention will ultimately guide your clinical reasoning. 

  1. The risk of a vascular incident caused by therapeutic intervention is extremely low. 

It is important to remember the relative risk of a vascular accident occurring. It is likely that the medications people take have a higher risk of causing a vascular accident compared to physical intervention. Again, using the framework will help guide your clinical decision and the fact that the risk is low does not mean you cannot consider the possibility of a vascular event from happening. 

  1. Shared clinical decision making is critical to planning your intervention. 

The article highlights a method of shared clinical decision making called “The SHARE Conversation” (table 10). Because some interventions for head and neck pain include craniocervical movements, it is important that your patient weighs in on their thoughts and goals for treatment. As a provider, your responsibility is to determine the relative risk associated with the patient’s presentation and contraindications in performing certain interventions. Then you initiate the SHARE conversation. The steps include:

  1. Seek the patient’s participation
  2. Help the patient explore treatment options
  3. Assess the patient’s values and preferences
  4. Reach a decision with your patient
  5. Evaluate the patient’s decision

Make sure to include this framework in your clinical decision making to foster the inclusion of the patient’s values and unique needs.

Summary

If you got to the end of this blog post and thought “Great, so it all depends…” then yes, it does depend. In the article, they include several case studies that work through a synopsis, history, clinical reasoning, and action. They also rate a vascular hypothesis on a continuum, which for me was a very helpful visual when going through each case. My suggestion is to visualize your clinical decision making on a continuum and that there is no “right” answer when you’re working in the gray zones of relative risk and different patient presentations in the context of vascular pathologies. But this framework does present a more objective and informed way of making decisions that all PTs should follow in all practices and settings. I hope you find this helpful in your own scope of practice and that you share it with your colleagues to improve patient care. 

  1. International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention: International IFOMPT Cervical Framework. Alison Rushton, Lisa C. Carlesso, Timothy Flynn, Wayne A. Hing, Sidney M. Rubinstein, Steven Vogel, and Roger Kerry. Journal of Orthopaedic & Sports Physical Therapy 2023 53:1, 7-22