Editorial

Bridging the gap across fields of practice

Physiotherapists are working more collaboratively inthe musculoskeletal and neurological fields withpostural stability and motor control emerging as acommon area of focus. This has led to a reduction inthe polarized position of physiotherapists with anyperceived gap gradually being bridged throughidentifying common ground and developing colla-borative research opportunities which focus onimproved outcomes for clients.One catalyst for this change in our institution has

come through a productive collaboration betweenphysiotherapists researching and working withchronic whiplash associated disorders (WAD) andthose working with traumatic brain injuries (TBI).Many of the chronic WAD clients were presentingwith unsteadiness and dizziness, making it timely toexamine this problem from a broader perspective(Treleaven et al. 2002). As a physiotherapist workingand researching with clients following TBI whereunsteadiness and dizziness are also present, theopportunity to collaborate with colleagues ‘acrossfields of practice’ was most welcome and has led toongoing and constructive outcomes.A study to examine standing balance control

between WAD clients with complaints of dizzinessand/or unsteadiness demonstrated increased instabil-ity in comfortable stance tasks on both a firm and afoam surface, particularly when vision was removed;and when the base of support was narrow, such astandem stance. These findings support the recom-mendation that physiotherapists working with WADclients should examine the postural mechanisms morethoroughly and use tasks that challenge balance inthe initial and subsequent assessments (Treleavanet al. submitted).For this recommendation to be effectively ad-

dressed by physiotherapists in the musculoskeletalfield, it is critical that knowledge of the visual,somato-sensory and vestibular contributions to bal-ance (postural stability) are understood and that thepractical skills of assessing balance by sequentiallychallenging these systems is clear. For example,bilateral stance on a firm surface with vision removedrequires the somato-sensory and the vestibularsystems to work together to ensure optimal balance;when a foam (soft) surface is introduced, the somato-sensory system is less reliable and thus vestibular

signals are required to ensure stability. The morechallenging tandem stance test implicates somatosen-sory and vestibular systems when vision is removed(Shumway-Cooke & Horak 1986; Woollacott 2000).Thus to prepare the musculoskeletal clinician, theknowledge, skills and interpretation of balance andmobility assessments need to be addressed in under-graduate programmes and applied in the ‘non-

neurological’ context as well as to ageing clients andthose with neurological dysfunction. In addition,post-graduate programmes in the musculoskeletalfield need to reconsider these elements at a moreadvanced level to ensure optimal delivery of manage-ment programmes for WAD, and other non-neuro-logical clients. In this regard, the treatment ofpostural instability following WAD and other mus-culoskeletal injuries needs to be addressed andconsider the tasks that challenge the visual, somato-sensory and vestibular systems. From a neurologicalperspective this would mean progressing from astable surface and well-lit environment with eyesopen to mastering balance on variable surfaces, withadded weight shift and movement towards the limitof stability. Additional challenges can include work-ing with the client in dim lighting and by removingvisual cues (Horak et al. 1997; Shumway-Cookeet al. 1997). Consideration of these multiple aspectsof postural control in the management of all non-neurological disorders should reduce the perceivedtendency to relegate, to the ‘neurological box’,valuable knowledge and skills acquired during basictraining as a physiotherapist.A second aspect that is being investigated by the

research team is the relationship between dizziness,ocular control and postural stability in chronicWAD. Smooth pursuit difficulties and increased jointpositioning error have been identified in chronicWAD, which together, may contribute to increasedunsteadiness and visual disturbance and may beassociated with complaints of dizziness (Heikkila &Astrom 1996; Tjell & Rosenhall 1998; Treleaven et al.2002). The contributions of the visual, somato-sensory and vestibular systems to ocular control arewell known with the importance of the vestibularocular reflex (VOR) to enable gaze stability duringhead movements established (Baloh 1998; Herdman,2000). The vestibular contributions to gaze instability

Manual Therapy (2003) 8(2), 63–65r 2003 Published by Elsevier Science Ltd.1356-689X/03/$ - see front matterdoi:10.1016/S1356-689X(03)00005-5

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and dizziness associated with head movement isfrequently addressed by physiotherapists workingwith clients following primary vestibular pathology(Horak et al. 1992; Krebs et al. 1993; Shepherd &Telian 1995) and TBI (Shumway-Cooke 1992; Gizzi1995; Fitzgerald 1996). These need to be consideredalso by physiotherapists working with WAD. Thecontribution of the cervical afferents to the cervicalocular reflex (COR) is currently being researched andthe cervicogenic cause of dizziness following WAD istopical and receiving attention by researchers withinand beyond our research group (Petersen et al. 1985;Tjell & Rosenhall 1998; Bracher et al. 2000; Wrisleyet al. 2000; Treleaven et al. submitted).The challenge for the manual therapist working

with cervical dysfunction and WAD in particular, isto attempt to differentiate between the multiplecauses of ocular instability and dizziness and identifythose that are amenable to physiotherapy interven-tion. Questions for consideration include: Has theacute trauma following WAD caused abnormalafferent input from the cervical mechanoreceptorsand thus contributed to symptoms of dizziness,unsteadiness and visual disturbances? Could thetrauma at the time of the WAD have caused damageto the vestibular receptor apparatus with hair cellsbeing dislodged to form free floating particles in thesemi-circular canals which cause intermittent dizziness

associated with specific head movements i.e. accordingto the canal involved—benign paroxysmal position-ing vertigo (BPPV)? Could the WAD be accompaniedby a mild head injury and/or concussion which maycomplicate the WAD presentation? Have there beencircumstances to involve the vertebral artery? It iscritical that all physiotherapists know how to conducta comprehensive assessment that may enable moreeffective differential diagnosis of the cervical, vestib-ular and central nervous system contributions toocular instability, dizziness and balance. A combina-tion of a careful history and well-directed clinicalexamination should ensure that the contribution ofthese systems to ocular stability, dizziness andpostural control are considered. The findings needto be documented using outcome measures tomonitor progress (Jacobsen & Newman 1990; Tesioet al. 1999; Whitney & Herdman 2000; Murray et al.2001; Shumway-Cooke & Woollacott, 2001). Addi-tional investigations can be offered by neurologistsand neuro-otologists to assist with differential diag-nosis and exclude other causes of ‘dizziness’ that maybe outside our realm of practice.The dizziness caused by BPPV and other vestibular

pathology, TBI and that of cervicogenic origin are allamenable to intervention by a physiotherapist.Specific protocols for BPPV are more established.The diagnosis of BPPV is confirmed by the Hall-PikeDix Test and simple re-positioning manoeuvres(depending on the canal implicated) can be applied

to ‘move the particles’ toward the vestibule where re-absorption may occur (Lynn et al. 1995; Epley 1996;Wolfe et al. 1999; Blatts et al. 2000). A possiblescreening test for cervicogenic dizziness is beinginvestigated with application of the smooth pursuitneck torsion test yielding promising results (Tjell &Rosenhall 1998). In this test, eye pursuit is examinedand then the trunk is rotated up to 451 while the headis held stationary and maintained in this positionbefore reintroducing eye movements. A change inthe quality of smooth pursuit eye movements in the‘torsioned’ position compared to the ‘neutral’ posi-tion suggests that cervicogenic dysfunction is con-tributing to the complaints of dizziness andunsteadiness (Tjell & Rosenhall 1998; In Press.).Once the cause(s) of dizziness are considered, atailored series of exercises involving eye and headmovements with and without vision could beintroduced to address the dysfunctional systems(Shumway-Cooke 1992; Revel et al. 1994; Gizzi,1995; Herdman, 1997, 2000). The prevalence ofdizziness, unsteadiness and accompanying gaze in-stability following WAD requires that protocols beadopted to ensure that dizziness is addressed and thatretraining ocular stability and balance is an integralpart of WAD management.It has become clear from the association with the

WAD research group that the neuro-motor control ofmovement is as relevant to the musculoskeletal fieldof practice as that required for the physiotherapistworking in the neurological arena. Such mutualcollaborations can only take a broader view forpractice forward and help to minimize the potentialfragmentation that may beset our profession as thenumber of physiotherapists who are specializingincrease. While the physiotherapist does need todevelop expertise in a specific field, it is critical toretain the broadest perspective for optimal clientoutcomes. It is in this climate of collaborativeresearch and practice that the profession shouldeffectively move forward.

Nancy Low Choy

Department of Physiotherapy,

The University of Queensland,

Australia

E-mail address: n.lowchoy@shrs.uq.edu.au

References

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Editorial 65

Manual Therapy (2003) 8(2), 63–65 r 2003 Published by Elsevier Science Ltd.