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Picture

Assessing VBI before cervical manipulation: should we test for it? 

5/5/2014

7 Comments

 
Picture
There is a common fear in treating the cervical spine (especially the upper portion) manually due to risk of injury. With the potential for damaging the vertebrobasilar artery system in the cervical spine, many people stray away from performing cervical manipulations. There have been a few situations where patients have died of ischemia following a cervical manipulation. The fatal reaction (and associated risk for lawsuit) to something that we can do as health care practitioners may discourage some from learning how to effectively apply manual therapy to the region. Is there really that much risk to injury? And what can we do to assess it?

As with any fatalities in the health care system, media (and other professional disciplines) will try to make the public aware of the risk for injury following a treatment. The same case applies to cervical manipulations. Some people have a somewhat irrational fear of this technique following media coverage and word of mouth. But how much risk is there really? NSAIDS have a .0004% annual mortality rate (Vizniak 2015). There is a .00005% chance of dying from a lightning strike each year. With cervical manipulations, there is a .00002% risk of death. This means you are more likely to die from taking NSAIDS or being struck by lightning than a cervical manipulation.

That being said, it is essential that proper patient selection is done before even considering this type of treatment technique. Start with patient history. Any patient with ligament laxity, rheumatoid arthritis, long-term corticosteroid use, osteoporosis/-penia, Down's Syndrome, osteoarthritis, and VBI be excluded. Naturally, we should perform our structural integrity tests and blood flow tests. We recently completed a review of the upper cervical spine that may prove beneficial reading as well. The structural integrity tests should at least include Transverse Ligament Test (and/or Sharp Purser Test), Alar Ligament Test, and a test for a Jefferson's Fracture. This last test is completed by compressing the transverse processes of the Atlas to assess for integrity. A positive test will occur with lack of stability or reproduction of neural symptoms. The artery test that is commonly performed is for Vertebrobasilar Insufficiency (VBI).
While the test we show displays combined end-range motions, some say this is not necessary. With the manipulation techniques staying closer to mid-ranges, some suggest just performing complete rotation when assessing. In theory, combined rotation and extension significantly closes off the vertebral arteries greater than rotation alone.

Now, the real question is: should we perform the Vertebral Artery Test? A compilation of studies revealed that there is a 0% sensitivity and .67-.90% specificity for the test (Cope et al, 1996). What this tells us is that a negative test means absolutely nothing and a positive test means a patient may have VBI. The testing we perform cannot rule out or rule in VBI. Vertebrobasilar Insufficiency is essential to consider as many of the symptoms mimic other orthopaedic cervical spine conditions: headache, neck pain, etc. (along with more traditional VBI symptoms - see link for symptoms). Even though there is poor diagnostic accuracy associated with the Vertebral Artery Test, it is recommended that the test be performed. There is a traditional thought that the vertebrobasilar artery system be tested prior to any manual therapy, no matter how poor the test is. Due to the media's perception that cervical manipulations risk VBI, any sign of "negligence" by not performing the test would likely place blame on the practitioner. As with any treatment technique, evaluate each patient individually for the potential benefit and associated risk factors prior to performing. In addition to performing the VBI test, Jim and I agree that the therapist should perform a pre-manipulative hold prior to any thrust procedure. The pre-manipulative hold allows the therapist to see how the patient will respond to the manipulative position prior to performing the thrust technique. Finally, we recommend following that process up with a "gut check" as well. Is the risk of the technique worth the reward/ benefit the patient will experience? Not everyone needs or should have a manipulation, but there are some instances where it has been shown to be highly beneficial.

-Chris

References:

Cote P et al. J Manipulative Physiol Ther. 1996.

Vizniak, Nikita. Spinal Manual. Canada: Professional Health Systems, Inc, 2015. 156-157. Print.
7 Comments
Steve
5/10/2014 09:33:01 pm

I'd advise that all PT's doing HVLAT's the the cervical spine, especially upper cervical or using rotation, read the document at ifompt.com. It is free and represents the best consensus on screening the vertebral artery. There is much more in the history we should be aware of than is reported here.
Its good to bring this to our attention.

Reply
Chris link
5/12/2014 01:56:43 pm

Hi Steve,

Thanks for your comment and that excellent resource! There definitely are many more considerations to look at before performing a cervical manipulation. This post was directed primarily at whether or not a test for VBI was worthwhile. This is in no way a guideline for when to perform a cervical manipulation.

Reply
Mary
6/14/2014 12:04:56 pm

Hi Chris!
I'm a 2nd year PT student in the middle of my ortho spine course. My professor had the exact same reasoning: figure out of this patient would actually benefit from a cervical manip (patient selection is key), look for red flags, and while the test might not tell you anything, do it anyway so that in the event of an adverse reaction you can demonstrate you did everything possible with the tests available. Glad we're on the same page.

Love the blog! This is such an awesome resource. Thanks!
-Mary

Reply
Jerry Hesch link
6/27/2014 11:10:13 am

Hi Chris,
Well written. Thank you.
I prefer not to test, agree with your gut feeling comment but of course history and medication and overall health, body type play a role in clinical "intuition".
I choose not to test, and I choose to treat the upper cervical and craniocervical junction by first clearing reflex influences such as the subtalar joint, talocrural, and the hips and pelvis. The AA is a very common site of compensatory restriction for lower body restrictions.
I treat the OA and AA in a fairly neutral position, less than 10 degrees of side bending and rotation and find very gentle albeit prolonged serves the clients well. Prior gentle ligamentous testing does occur, whereas VBA testing does not. Just my personal approach with no attempt to change what others do, except when I am teaching in a formal workshop.
Thank you again.
Best Regards,
Jerry Hesch

Reply
Jerry Hesch link
6/27/2014 11:10:21 am

Hi Chris,
Well written. Thank you.
I prefer not to test, agree with your gut feeling comment but of course history and medication and overall health, body type play a role in clinical "intuition".
I choose not to test, and I choose to treat the upper cervical and craniocervical junction by first clearing reflex influences such as the subtalar joint, talocrural, and the hips and pelvis. The AA is a very common site of compensatory restriction for lower body restrictions.
I treat the OA and AA in a fairly neutral position, less than 10 degrees of side bending and rotation and find very gentle albeit prolonged serves the clients well. Prior gentle ligamentous testing does occur, whereas VBA testing does not. Just my personal approach with no attempt to change what others do, except when I am teaching in a formal workshop.
Thank you again.
Best Regards,
Jerry Hesch

Reply
Jerry Hesch link
6/27/2014 11:11:41 am

Hi Chris,
Well written. Thank you.
I prefer not to test, agree with your gut feeling comment but of course history and medication and overall health, body type play a role in clinical "intuition".
I choose not to test, and I choose to treat the upper cervical and craniocervical junction by first clearing reflex influences such as the subtalar joint, talocrural, and the hips and pelvis. The AA is a very common site of compensatory restriction for lower body restrictions.
I treat the OA and AA in a fairly neutral position, less than 10 degrees of side bending and rotation and find very gentle albeit prolonged serves the clients well. Prior gentle ligamentous testing does occur, whereas VBA testing does not. Just my personal approach with no attempt to change what others do, except when I am teaching in a formal workshop.
Thank you again.
Best Regards,
Jerry Hesch

Reply
Jerry Hesch link
6/27/2014 11:13:15 am

Hi Chris,
Well written. Thank you.
I prefer not to test, agree with your gut feeling comment but of course history and medication and overall health, body type play a role in clinical "intuition".
I choose not to test, and I choose to treat the upper cervical and craniocervical junction by first clearing reflex influences such as the subtalar joint, talocrural, and the hips and pelvis. The AA is a very common site of compensatory restriction for lower body restrictions.
I treat the OA and AA in a fairly neutral position, less than 10 degrees of side bending and rotation and find very gentle albeit prolonged serves the clients well. Prior gentle ligamentous testing does occur, whereas VBA testing does not. Just my personal approach with no attempt to change what others do, except when I am teaching in a formal workshop.
Thank you again.
Best Regards,
Jerry Hesch

Reply



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