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Vertebrobasilar Insufficiency: What Do You Do?

2/24/2015

13 Comments

 
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With the physical therapist's increased emphasis on incorporation of manual therapy when treating the cervical spine, the concern of vertebrobasilar insufficiency is frequently discussed. Even though fewer people have adverse effects from cervical manipulations compared to NSAID's, there is still a stigma revolving around the disease, and rightfully so. Part of the reason the incidence of adverse effects following cervical treatment is due to appropriate screening methods. We all know that the Vertebral Artery test has insufficient psychometric properties for diagnosis. If a test is negative, it doesn't change anything. If it is positive, the patient might have VBI. The sensitivity and specificity of the test is so low that some clinicians actually prefer not using the test. Personally, I still use it, due to the public perception that it is required for "screening"; however, I consider the diagnostic accuracy in my clinical reasoning. What is more beneficial in the screening process is a thorough subjective history. There are signs and symptoms that increase the likelihood of the patient having the disease. We should be asking about nausea and vomiting, the 5 d's (dizziness, drop attacks, diploplia, dysphagia, dysarthria), and look for nystagmus. Also, consider other past medical history like cardiovascular disease. Most programs and manual therapy classes spend time going through how to properly take the subjective and what to look for when determining the likelihood of VBI. So what do you do when both the subjective and objective are ruling in VBI?

I recently had a patient with "neck pain" come to my clinic for an evaluation. I noticed immediately that the patient had a sense of caution when turning her neck. She described her neck pain extremely vaguely on both sides of her cervical spine and upper trap. As part of my screening process for upper quarter patients, I ask about dizziness, N&V, and a few other questions that are linked to various pathologies. The patient reported she did have some dizziness when turning her head and changing positions. Initially I suspected BPPV, but also wanted to continue exploring other possible symptoms. The patient reported dizziness, fainting, blurred vision when turning her head, and difficulty forming words occasionally. That is 4/5 D's and she ended up having positive nystagmus with full cervical rotation after about 10 seconds which also recreated her dizziness. The patient apparently never told the doctor about her dizziness, fainting, or trouble speaking because she thought they were unrelated. Additionally, the patient reported a history of HTN and was in her upper 50's.

Having never actually encountered someone with a collection of these S&S that may be associated with VBI, I knew I would not perform treatment without further work-up by the physician. I called her doctor and they wanted her to come in that day. I was unsure; however, if, had I not been able to get a hold of the doctor, should I have sent her to the ER. She had been walking around with these symptoms for 6 months, but with the risk for stroke, should we be referring these patients to the ER? It is a tough decision that may be based on each patient's individual presentation. We don't want to send any patient with neck pain and dizziness to the hospital. A single "red flag" does not have much clinical value, but a collection of them does and we need to act appropriately. What do you think is the next correct step?



-Chris

13 Comments
mary
2/25/2015 08:35:40 pm

U did the right thing I have had this happen...I work alot with vestibular pts too..chances are if u think its something more serious Ur right, now finding someone to properly do the right rest and assess them medically now that's another story right?!! I like Ur blogs by the way!!

Reply
researching therapy link
2/26/2015 01:09:41 am

As mary said, the tough part is finding someone who will treat them properly! Good Luck!

Reply
Ruud de Beijer NL link
2/26/2015 08:25:54 pm

I read your case story with a lot of interest. It's indeed a tough decision. Your patiënt does have some serious symptoms that could be connected with VBI. Good luck!

Reply
Steve
3/3/2015 01:26:49 am

A few things:
1. Refer! See if the cause of the symptoms can be found. Arterial? Vestibular? Joint?
2. If this were acute, I would refer to ER. Possible CVA in progress.
3. While I am not aware of %-ages of likely artery involvement as these clusters increase, she has enough that I would not treat until she had at a minimum: x-ray, arteriogram, caratoid US...and maybe an MR.
4. Certainly NOT a manip candidate and not a patient that should be seen by anyone other than a PT.

Reply
Chris link
3/3/2015 03:59:56 am

Hi Steve,

Thank you for your comments. I absolutely agree. After her evaluation, I sent her to the doctor and spoke with their office to get her in. I refused to do any treatment on her that day until cleared, even though this had been going on for months. Thanks for your input!

-Chris

Reply
Greg
3/6/2015 11:56:13 pm

Hey Chris, 2nd year studemt here. While I knoe this is absolutely of secondary concern behind the patient's safety, how did you handle explaining to the patient your concerns without scaring her and was she upset that you wouldn't treat her?

Warda
10/1/2018 09:12:24 am

I have a similar case. Pt has sx of VBI post MVA. She also has bicep tear and teres major and infraspinatus pathology. Coming from a third world country, our doctors are loaded so my pt can only seen at the end of this month! Her injury was about a month ago. I've been advised to keep seeing her for her other injuries but I'm concerned that nothing is being done about the VBI. Could I work on cervical stability at least? What treatment would the doctors provide anyway? (A common mismanagement is painkillers :/)

Reply
Chris link
3/7/2015 11:33:15 am

Hi Greg,

Thank you for your comments. First of all, the patient was extremely grateful for me sending her back to the doctor given the concern of the treatment. I think she was just happy someone was kind of "connecting the dots" for her. She had some symptoms she hadn't told anyone about and they all came together. Since the patient had had these symptoms for 6 months, it didn't appear she was ready to die that second given no change in the symptoms, but that doesn't mean medical attention wasn't required. I just educated her on what could be going on, and why it was important to get it cleared first. Patients are (almost) always grateful for when you are looking out for them. I have only once had a patient upset with me for something like that (I didn't want a patient to begin aquatic therapy until she had a rash on her foot checked out by an MD due to risk of infection to other patients). If you have any other questions, let me know!

-Chris

Reply
susie link
12/2/2017 09:55:49 pm

i have vbi for years and docs wont do nothing about it.. im so dizzy tonight i cant even walk. major neck pain and fingers and toes numb.. wish i can find a doc to help me.. im almost 60

Reply
zainab Hasan Ali
4/11/2018 10:06:27 am

Hy,i am doing internship in hospital, pt department, i saw a patient, having spondylosis at c5-c6 level, having spasm around neck ,on treps specially ,her doc send her to pt on her frst visit pt did hot pack thing then stretching of neck ,when i asked her (pt) about her vbi test she said its posotive she was also feeling numbness in her limbs specially in right hand, she was depressed as well, now question is, is. It permissible to perform any stretching or any physical treatment despite being knowing that she was feeling dizziness on every movement of her neck and vbi is positive?

Reply
TSPT- Jim
4/22/2018 08:36:48 pm

I would do some further workup and testing personally. It sounds like her symptoms could be either radiculopathy OR VBI. If you retest VBI and it is positive, I would not perform any stretching until further work up.

Reply
Donna Carter
6/12/2019 06:51:12 am

I have been diagnosed with VBI and have lost vision temporarily 3 times (once while driving). My PCP doesnt seem to know what to do about this or who to refer me to. Do I need to see a neurosurgeon or a vascular surgeon? Headaches and neck pain are killing me.

Reply
TSPT
6/12/2019 07:10:44 am

We would recommend following up with a vascular surgeon or cardiologist. Good luck!

Reply



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