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disturbances, (3) headache, and (4) right shoulder region pain. Clinical VBI tests were performed, central and peripheral vestibular
whereby the patients vertigo and visual disturbances were reproduced with cervical spine system.32,33 Disruption of normal
extension. The patient was sent back to the referring physician to be evaluated for possible VBI. blood flow in this area can pro-
Diagnostic imaging tests were ordered. Carotid ultrasound revealed 80% to 90% stenosis in the duce any of the following symp-
proximal left internal carotid artery, and magnetic resonance angiography of the extracerebral toms: nausea, vertigo and syncope,
vessels showed greater than 90% stenosis of the left internal carotid artery. and swallowing, speech, balance,
Copyright 2005 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
Discussion: VBI may be present in patients with subjective reports of vertigo and visual auditor y, and visual distur-
disturbances that are reproduced with VBI physical examination procedures. J Orthop Sports Phys bances.4,8,13 Inadequate perfusion
Ther 2005;35:645-650.
to these areas of the brain can
Key Words: cervical spine, direct access, neck, primary care, vertebral artery produce symptoms that usually
have a rapid onset, vary in dura-
tion and frequency, and may occur
S
creening patients for potentially serious medical conditions is
in isolation or in some combina-
one of the most important components of a physical thera-
tion with one another.10,11
pists examination. It should not be assumed that a patient has Retrospective studies have re-
R E S I D E N T S C A S E P R O B L E M
undergone adequate medical screening, despite referral from
Journal of Orthopaedic & Sports Physical Therapy
associated with VBI are provoked during or after the audiogram to assess for inner ear disorders. Lesions
physical examination procedure, then physical to the inner ear and vestibulocochlear nerve (cranial
therapy intervention and especially cervical spine nerve VIII) can produce vertigo along with auditory
manipulation are considered to be contraindicated.1 symptoms such as hearing loss, tinnitus, sensation of
pressure or fullness in the ear, or ear pain.3,37 The
However, 27 patients who developed cerebrovascular
patient was found to have asymmetrical hearing loss,
Copyright 2005 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
valid diagnostic tool for detection of carotid The patient was seen in physical therapy 4 days
stenosis.34 Magnetic resonance angiography (MRA) later. During the subjective evaluation the patient
has also been shown to have excellent sensitivity and identified the following 4 complaints: (1) intermittent
specificity in picking up distal vertebral artery pa- vertigo lasting approximately 1 minute when turning
thologies.30 Nevertheless, evaluating the smaller the head to the right, (2) visual changes, described as
branches of the vertebrobasilar circulatory system black spots and distortion in her right eye,
remains limited even with these imaging studies.2 which could last up to a half hour and were
VBI is considered to be a rare but unpredictable reportedly becoming more frequent, (3) occasional
condition that is not easily detected from data col- right frontal-occipital area headaches, and (4) inter-
lected during the history and physical examination.13 mittent right shoulder area pain.
In the absence of clear evidence, a reasonable ap- Medications taken at this time were ibuprofen for
proach is to err on the side of avoiding harm. The headache, and triamterine, and conjugated estrogens
purpose of this residents case problem is to describe for hypertension.
a case where the patients history and physical
examination suggested the presence of VBI, which Physical Examination
was verified with diagnostic imaging. This case also The patient did not experience any of the afore-
serves to demonstrate appropriate measures taken for mentioned complaints while sitting upright during
a patient with clinical findings consistent with VBI. the subjective examination. Given the history of
R E S I D E N T S C A S E P R O B L E M
tients blood pressure was measured and found to be message was left on the physicians voicemail system
Journal of Orthopaedic & Sports Physical Therapy
130/70. Active cervical range of motion was then to inform him of the significant findings. The patient
assessed in a sitting position. Active cervical move- was advised to delay further physical therapy services
ments were observed to be within normal limits until receiving clearance by her physician. She was
although specific goniometric measurements were also advised to avoid any symptom-provoking posi-
not taken. The patient did report a pulling sensa- tions of her neck and to monitor any changes or
tion on the right side of the neck at the end ranges occurrences of any signs and symptoms she might
of flexion, left rotation, and left side bending. Upon encounter.
returning to a midline head position the pulling
sensation had resolved for all the provocative move- Diagnostic Testing
ments. No other symptoms were reported with active Shortly after a follow-up visit with her physician,
cervical movements. cervical spine radiographs, carotid ultrasound, mag-
An attempt was then made to detect the existence netic resonance angiogram (MRA), and magnetic
of VBI as a possible cause of the patients vertigo, resonance imaging (MRI) were ordered. Cervical
visual disturbances, and neck pain. The APA protocol spine radiographs and MRI yielded normal results.
for vertebral artery testing was used.24 Initial testing Carotid ultrasound revealed 80% to 90% stenosis in
using this protocol includes sustained end range the proximal left internal carotid artery. MRA find-
rotation only, performed either in a supine or sitting ings demonstrated greater than 90% stenosis of the
position. In addition to cervical rotation, cervical same artery. A medical diagnosis of left carotid artery
Reproducing the patients vertigo and visual hallu- provide adequate blood supply during the occlusion
cination of black spots with the passive cervical of the vertebral artery screening tests. Indeed, it has
extension portion of the physical examination sug- been suggested that VBI screening tests essentially
gests VBI as a possible cause of the patients evaluate the status of collateral circulation in the
symtoms.1,24 Although, symptoms of vertigo that are presence of a compromised vertebral artery.29 The
associated with head and neck movements can have a results of this case report support this premise. Our
Copyright 2005 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
vestibular or cervicogenic origin as well. Among these patient demonstrated greater than 90% stenosis of
differential diagnoses, VBI has the potential to de- the left internal carotid artery during MRA. Perhaps
velop into the most serious condition and therefore, this amount of occlusion in the left carotid artery was
should be evaluated first. An attempt to rule in or sufficient to prevent adequate perfusion of brain
rule out VBI as the primary diagnosis was made by tissue while the patients head was held at an end-
using a provocative screening exam despite the poor range extension position.
sensitivity and specificity associated with such Confirmation of suspected cerebral ischemia was
tests.6,12,13,22 Although, exposing the patient to this confirmed with carotid ultrasound and MRA. The
provocative physical examination procedure may have importance of being able to convey our subjective
Journal of Orthopaedic & Sports Physical Therapy
theoretically increased the potential for causing and objective examination findings to the patients
harm, this potential was minimized by closely moni- physician was pivotal in facilitating the patient
toring the patient during the procedure. The poten- through the appropriate channels of care. It is
tial benefits of eliciting positive results that expedited important to be well versed in the clinical decision
the patients scheduling of the definitive diagnostic making process when patients present with vertigo or
imaging were felt to outweigh the risks. Additionally, visual disturbances. Being knowledgeable about ap-
there is no evidence in the literature that the propriate diagnostic studies and medical management
performance of such a test is harmful. Because the (medications, surgical options) is essential for effec-
test was found to be positive, along with the patients tive communication with other health care practitio-
subjective examination findings, the decision was ners.
made to cease further physical therapy examination Having a working knowledge base of the potential
or intervention until the diagnosis of VBI could be differential diagnoses is also essential in the delivery
ruled out with certainty. Had the test been negative, of standard care. Because vertigo and visual distur-
the authors would have considered cautiously examin- bance symptoms are also associated with vestibular,
ing the patient for musculoskeletal impairments in vascular, or cervicogenic disorders, the authors did
addition to referring the patient back to her physi- attempt to collect data in the physical examination to
cian. at least rule in or rule out such disorders. Keeping in
Failure to acknowledge the potential of false nega- mind that the priority of vascular compromise was of
tive results when using VBI screening tests can lead to primary concern, the authors felt the need to justify
R E S I D E N T S C A S E P R O B L E M
1. Australian Physical Therapy Association. Clinical
Journal of Orthopaedic & Sports Physical Therapy
think established dogma? Ear Nose Throat J. disease: comparison with angiography. J Ultrasound
1998;77:966-969, 972-964. Med. 1986;5:247-250.
22. Kunnasmaa K, Thiel H. Vertebral artery syndrome: a 36. Westaway MD, Stratford P, Symons B. False-negative
review of the literature. J Orthop Med. 1994;16:17-20. extension/rotation pre-manipulative screening test on a
23. Licht PB, Christensen HW, Hoilund-Carlsen PF. Carotid patient with an atretic and hypoplastic vertebral artery.
artery blood flow during premanipulative testing. Man Ther. 2003;8:120-127.
J Manipulative Physiol Ther. 2002;25:568-572. 37. Wrisley DM, Sparto PJ, Whitney SL, Furman JM.
24. Magarey ME, Rebbeck T, Coughlan B, Grimmer K, Cervicogenic dizziness: a review of diagnosis and
Rivett DA, Refshauge K. Pre-manipulative testing of the treatment. J Orthop Sports Phys Ther. 2000;30:755-766.
Journal of Orthopaedic & Sports Physical Therapy