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Vestibular Rehabilitation A forum for the discussion of vestibular dysfunction including dizziness, vertigo, and balance problems.

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Old 28-09-2009, 03:29 AM   #1
Gustavo Pacheco de Souza Cruz
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Default VBI test

To continue the VBI test as EMAD said is important, this link is interesting about its risk factors.

http://www.theamericanchiropractor.c...=51&category=7

Another interesting point is: How this test could be done? I learned two ways:

1- patient lay down, cervical region in extension and right rotation - to test the right artery and left rotation to test the left artery.

2- patient seated, some degrees of trunk flexion and the head in THE SAME INITIAL POSITION (neutral position) and then, the patient turn the head to the side that will be tested.

The main point here is that the number 1 is the same position that the Dix-Halpike test, so if the therapist do the test and the nystagmus or dizziness, where is the problem? Vestibular or VBI????

The number two resolves this problem because when the head keep on the neutral position, the vestibular system is not involved.

What do you think???
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Old 28-09-2009, 09:20 PM   #2
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if you are doing vertebral artery testing and have any suspicion of BPPV, a seated variation is preferable to eliminate the possibility of the symptoms in the test postion being from BPPV. If a supine version is necessary for some reason, remember that in typical BPPV (canalithiasis), the vertigo and nystagmus will subside inside of 60 seconds, which wouldn't be the case with VBI. VBI will also likely have additional neuro signs such as slurred speech. Keep in mind the validity of any of the VBI tests is suspect anyway.

Tony Friese, PT
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Old 29-09-2009, 02:37 AM   #3
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Agree with Tony.
I think these tests are invalid and may be worse than useless.
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File Type: pdf Cx Stop VBI Testing 2005.pdf (183.6 KB, 65 views)
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Old 29-09-2009, 03:14 PM   #4
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Hallo gustavo,and all:
I do apply VBI from sitting just rotation coombined with subjective hisotry and data given from the patient.
I agree testing sometimes could be risky ,it is the same point in testing nervous system through upper limb neurodynamic tests, test means stress over the system, however if we have very clear symporoms we do not need to perform the test ,or just very gentle and just stop with initial sympotoms.

The Vistibular system seems to be special in its reaction, headache ,tinnitus , dizziness could make the patient really uncomfortable,.

cheers
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Old 15-11-2009, 06:10 PM   #5
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Default another way to differentiate BPPV from VBI

Hello all,

I had a patient several months ago that I was unclear whether her symptoms were BPPV or VBI. A test I found in Magee that I do now is:
  1. Patient is standing
  2. Hold their head still
  3. Patient rotates trunk left and hold 30 seconds then repeat other side, asking about symptoms
No head movement means no input from the semi-circular canals so if they hav symptoms such as dizziness/lightheadedness you would suspect VBI more

I use this in conjunction with Dix-Hallpike to determine the source, or closest to the source, of the patient's symptoms

Agree with Jason and Tony, VBI test is unreliable. JOSPT a few months ago published this:

http://www.jospt.org/issues/articleI...cle_detail.asp

I now include Cranial Nerve testing in all cervical patients, BP testing, age (over 65 = > risk of carotid atherosclerosis), positional tests (pure flexion, pure extension), area of pain distribution, don't have a doppler unfortunately

John
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Old 16-11-2009, 05:36 AM   #6
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John,
I think that may be a valid test to rule out BPPV, but not so much to rule in VBI. Dizziness/light-headedness is as a common feature of chronic neck pain/injury.

In this recent Clinical Commentary from JOSPT, Kristjansson and Treleaven discuss the relationship between sensorimotor function of the cervical spine and dizziness:
Quote:
J Orthop Sports Phys Ther. 2009 May;39(5):364-77.
Sensorimotor function and dizziness in neck pain: implications for assessment and management.

Kristjansson E, Treleaven J.

Faculty of Medicine, The University of Iceland, Reykjavik, Iceland. eythork@simnet.is

SYNOPSIS: The term sensorimotor describes all the afferent, efferent, and central integration and processing components involved in maintaining stability in the postural control system through intrinsic motor-control properties. The scope of this paper is to highlight the sensorimotor deficits that can arise from altered cervical afferent input. From a clinical orthopaedic perspective, the peripheral mechanoreceptors are the most important in functional joint stability; but in the cervical region they are also important for postural stability, as well as head and eye movement control. Consequently, conventional musculoskeletal intervention approaches may be sufficient only for patients with neck pain and minimal sensorimotor proprioceptive disturbances. Clinical experience and research indicates that significant sensorimotor cervical proprioceptive disturbances might be an important factor in the maintenance, recurrence, or progression of various symptoms in some patients with neck pain. In these cases, more specific and novel treatment methods are needed which progressively address neck position and movement sense, as well as cervicogenic oculomotor disturbances, postural stability, and cervicogenic dizziness. In this commentary we review the most relevant theoretical and practical knowledge on this matter and implications for clinical assessment and management, and we propose future directions for research. LEVEL OF EVIDENCE: Level 5.
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Old 16-11-2009, 08:05 AM   #7
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While we are on VBI testing, there's something that bugs me about the 'VBI as safety precaution debate' and perhaps someone who is more familiar with the literature can help me out.

VBI testing aims to identify problems with arterial patency by directly challenging it. A positive test is interpreted as a sign to avoid the introduction of transitory (and often rapid) forces in a similar direction - forces that have been associated with perforation of the arterial wall, rather than ongoing mechanical blockage.

Do we know if 'insufficiency' is a risk factor for arterial dissection?
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Old 16-11-2009, 04:21 PM   #8
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I agree, Luke. It seems a lot of "extrapolation" is going on with the decision to perform VBI testing. My guess is that testing for VBI became popular with manipulative therapists because rarely a patient arrives who is unable to tolerate the "pre-manipulative hold," which often mimics the final stage of VBI testing, due to the production of red flag signs such as dysarthria, dysphasia, syncope or other cranial nerve signs.

Whether someone who is susceptible to these signs of insufficiency, which you'd think would be due to perhaps a combination of upper cervical degenerative changes and arterial plaques, is at higher risk for arterial rupture from a manipulative procedure is open for debate. It seems plausible.

On the other hand, it's also plausible that there are a group of patients who may have dys-/hypoplastic defects in one or both vertebral arteries who have no problems at all with having their head and neck positioned in a way that is designed to identify patients with insufficiency based on patency. The type of "insufficiency" displayed by these patients is of another category altogether, and I'm not aware of any clinical test that can identify it. This is the argument I use against performing thrust manipulation to the cervical spine. Regardless of how rare it is, if there is no way to clinically screen someone for a potentially life-threatening consequence of a procedure, should that procedure even be done?

Furthermore, there's evidence that in certain populations vertebral artery hypoplasia is not rare.

Any decent attorney could swiftly dismantle any argument for performing cervical manipulation based on a negative VBI screen.
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Old 17-11-2009, 06:22 AM   #9
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Here's an interesting commentary from BMJ on the features of cervical artery dissections.
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Old 17-11-2009, 03:15 PM   #10
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40% of the population have one hypoplastic vertebral artery. The left is dominant 50% of the time, and the right 25%.

Also, the traditional Circle of Willis picture in your texts is only complete in 25% of us. 50% have posterior circulation variation.

I'll chime in on the VBI testing later today whan I have some time.

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Old 17-11-2009, 08:27 PM   #11
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John you mean upper cervical manipulation?

I'll reiterate that I think these VBI tests are worse than useless.
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Old 18-11-2009, 05:04 PM   #12
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For years we were taught George's Test as a pre-screening tool for patients suspected to be at higher risk for VAD. In 2004 the Association of Chiropractic Colleges recommended that we cease this (and other) provocative tests.

The association found that....

The tests yielded too many false +/-'s.

They were not reliable.

They were too provocative.

Bottom Line: There are no reliable or safe tests that will r/o a VAD in progress and there are no tests that will ID a patient at risk for a VAD.

I was told that if your patient suffers an adverse event (following a cervical manipulation), you're going to get dinged either way. If you did it....it's unrelieable/useless. If you didn't....you missed a chance to prevent the VAD.

Here's three things I use to help prevent a VAD from occuring in my office.

1. HISTORY
2. HISTORY
3. HISTORY
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Old 19-11-2009, 12:37 AM   #13
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Quote:
John you mean upper cervical manipulation?
Pretty much, but it depends then on what kind of technique you use. The upper cervical region can get pretty wound up with some rotatory techniques in the mid cervical region.

Also, if the vertebral artery is hypoplastic, is it safe to assume that that means along its entire course? If so, it may be vulnerable to injury with even some of the "safe" traction manip's, which avoid rotatory forces in the mid and low cervical spine.

Fortunately, the evidence currently indicates that cervical mobs are as effective as manips. So, if you're going to tug on joints in the neck, then you may as well stick with the former, in my opinion.

Luckbox,

How is history going to help you rule out a hypoplastic vertebral artery in a young person (under 40's are at greatest risk for dissection with cervical manipulation) with no history of VBI?
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Old 20-11-2009, 08:52 PM   #14
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Short of a pre-manipulation MRA, I'm not going to r/o a hypoplastic vert. Regardless, their commonality depends on who you read, as does their role in posterior circulation infarcts.

My emphasis on History is simple. Headache/neck pain are the CC in vertebral artery dissections 80%+. HPI, PMH, FHx, SocHx, EnvHx.....Are what's going to best serve me when I'm trying to determine 'simple' HA/neck pain, or something more sinister.

How am I going to find out about the hypertensive, dyslipidemic, BC-pill taking migraineur with a history of hemifacial paresthesias and truncal ataxia if I don't communicate with her.

If one of your patients suffers an adverse outcome (God-Forbid) and you find yourself in court, you're more likely to get nailed because of something you missed in the history, not the absence of some neurological/orthopedic test.

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Old 20-11-2009, 09:20 PM   #15
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Quote:
Headache/neck pain are the CC in vertebral artery dissections 80%+. HPI, PMH, FHx, SocHx, EnvHx.....Are what's going to best serve me when I'm trying to determine 'simple' HA/neck pain, or something more sinister.
Any references with sensitivity/specificity statistics?

Perhaps an important historical feature is hx of cervical manipulation?

Quote:
J Neurol. 2008 Mar;255(3):371-7. Epub 2008 Jan 15.

The relation between the spatial distribution of vertebral artery compromise and exposure to cervical manipulation.
Kawchuk GN, Jhangri GS, Hurwitz EL, Wynd S, Haldeman S, Hill MD.

University of Alberta, Canada. greg.kawchuk@ualberta.ca

BACKGROUND AND PURPOSE : The vertebral artery is made up of four segments, one of which (V3) is connected to highly mobile cervical vertebrae. This connection underlies the common assumption that persons with pre-event histories of mechanical neck movements, such as cervical spine manipulation (cSMT), should experience increased V3 dissection. METHODS : Two of the largest case series of vertebral artery dissection describing subjects with and without a specific history of cSMT were reassessed to determine which segment(s) of the vertebral artery was most commonly compromised. RESULTS : The V3 segment was the most commonly involved vertebral artery segment in both the +cSMT group (e.g., V3 vs. V1 prevalence ratio (PR) = 8.46) and the -cSMT group (V3 vs. V1 PR = 4.00). However, V3 vulnerability was augmented by the effect of cSMT. The joint effect of V3 location and exposure to cSMT was greater than if each effect were simply combined. In addition,multiple site lesions were significantly more common than single sites in both the +cSMT group (PR = 2.67, p = 0.008) and the -cSMT group (PR = 2.44, p = 0.0008). CONCLUSIONS : In prior studies which identified vertebral artery compromise, those with a history of cSMT were more likely to have involvement of the V3 segment. Although this study does not identify a mechanism which relates vertebral artery dissection and exposure to cSMT, these data are compatible with a greater than additive relation between compromise of an arterial segment thought to be mechanically vulnerable and history of a mechanical event.

PMID: 18185906 [PubMed - indexed for MEDLINE]
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Old 20-11-2009, 10:10 PM   #16
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John,

Regarding your first question.

FROM: Can J Neurol Sci 2000 (Nov); 27 (4): 292–296

Saeed AB, Shuaib A, Al-Sulaiti G, Emery D


Department of Medicine, University of Alberta, Canada

BACKGROUND AND OBJECTIVES: Internal carotid artery dissection has been extensively studied and well-described. Although there has been a recent increase in the number of reported cases of vertebral artery (VA) dissection, the clinical variety of presentation and the early warning symptoms have not been well-described before. Our objectives in this study include: (1) To determine the early symptoms and warning signs which may help the clinician in the early identification and treatment of patients with VA dissection. (2) To explore the variety of clinical presentation of VA dissection and its relation to prognosis.

DESIGN AND SETTING: Retrospective analysis of hospital records in a tertiary academic centre for the period 1989-1999.

RESULTS: Twenty-six patients were identified (13 men and 13 women). The mean age was 48. Possible precipitating factors were identified in 14 patients (53%). Sporting activity and chiropractic manipulations were the most common (15% and 11% respectively). Headache and/or neck pain was the prominent feature in 88% of patients and was a warning sign in 53%, preceding onset of stroke by up to 14 days. The most common clinical features included vertigo (57%), unilateral facial paresthesia (46%), cerebellar signs (33%), lateral medullary signs (26%) and visual field defects (15%). Bilateral VA dissection presented in six patients (24%). The most common region of dissection was the C1-C2 level (16 arteries, 51%). Intracranial VA dissection was found in eight arteries (25%). The majority of patients (83%) had favorable outcome. Poor prognosis was associated with (1) bilateral dissection; (2) intracranial VA dissection accompanied by subarachnoid hemorrhage. Only two patients reported stroke recurrence.

CONCLUSIONS: Our findings show that VA dissection affects mainly middle age persons and involves both sexes equally. Headache and/or neck pain followed by vertigo or unilateral facial paresthesia is an important warning sign that may precede onset of stroke by several days. Although the majority of patients will have excellent prognosis, this was less likely in patients presenting with subarachnoid hemorrhage or bilateral VA dissection. Recurrence rate was low.

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Old 20-11-2009, 11:04 PM   #17
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John,

That's right it does not rule in VBI, it helps to give you a differential diagnosis between VBI and BPPV. The other tests (Cranial N, BP, doppler, etc.) can help to rule in VBI.

Agree also that a negative VBI does NOT provide a good defense and should not be a "green light" for manipulation.

Luckbox makes a good point on proper history taking, a lot of tragedies can be avoided with the right questions.

I read of one practitioner that manipulated the C-spine and the patient had mild VBI symptoms afterwards, but due to his ignorance dismissed the symptoms. The patient came in for the next visit, he manipulated her C-spine again and she died of VA dissection.

While we are on the subject, Kerry talks about the difficulty in diagnosiing/identifying at risk patients: http://nucre.com/Artigos%20-%20Colun...20arterial.pdf

This is where most of the testing recommendations I use come from.

If there is any doubt at all, then we should not be manipulating the C-spine, that's the bottom line.

John
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Old 20-11-2009, 11:28 PM   #18
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Thanks for that article, John. Looks good.

Quote:
If there is any doubt at all, then we should not be manipulating the C-spine, that's the bottom line.
When is there not doubt? That's what I'm asking.

Luckbox,

I don't understand how the clinical features of vertebral artery dissection provide any evidence for the validity of historical findings to predict vertebral artery dissection. That would be a tautology.

Aren't you concerned about preventing the initial incident, rather than just subsequent ones?
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Old 24-11-2009, 12:26 AM   #19
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Quote:
Luckbox,

I don't understand how the clinical features of vertebral artery dissection provide any evidence for the validity of historical findings to predict vertebral artery dissection.
John, I've read this sentence a few times and I'm still not sure what you're getting at. Could you rephrase it for me?
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Old 24-11-2009, 03:12 AM   #20
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Sure.

You provided an abstract of a study that described the clinical features of VAD so that these signs and symptoms can be recognized as early as possible and then appropriate treatment rendered. How does this study support your contention that a thorough history is going to prevent VAD? The patients in the study you cited have already had an injury.

I suppose what may be getting confused here is that certain patients will have primary c/o of neck pain, which could be due to a non-somatic source of nociception, such as VAD, and that this should be ruled out before proceeding with manipulation. While these patients can be difficult to screen in and of themselves, these are not the patients that I'm mostly concerned about. I'm concerned about the "accidents waiting to happen" for which there is no clinical test to reliably screen, i.e. those with hypoplastic vertebral arteries, who are at inherent risk of an initial injury from upper cervical manipulation.

What about the patient who routinely gets his upper cervical spine manipulated due to chronic HA or neck pain who then after 10 or 20 years of forming plaques and small blockages in the VAs in part due to small intimal tears finally suffers a posterior circulation stroke and dies? Do you think this is a plausible scenario? If so, what are the ethical obligations of the provider? What should be the elements of "informed consent" with regards to upper cervical manipulation? Do you think providers of this treatment should inform their patients that they may sustain damage to their VAs and that this could lead to deleterious consequences in the near or long term?
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Old 24-11-2009, 07:19 PM   #21
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Quote:
Here's three things I use to help prevent a VAD from occuring in my office.

1. HISTORY
2. HISTORY
3. HISTORY
I certainly can't guarantee against such an event, but a thorough History is the most valuable pre-manipulation assessment.


Quote:
I suppose what may be getting confused here is that certain patients will have primary c/o of neck pain, which could be due to a non-somatic source of nociception, such as VAD, and that this should be ruled out before proceeding with manipulation.
I don't disagree you, and it's far from limited to neck pain and VAD.

I've sent numerous patients to the ER to r/o MI. Many have been told by me to f/u with thier PCP to r/o gall bladder problems, kidney stones...etc. Pancreatic cancer is another that stands out.

Have you ever noticed that these things occur in clusters? Hypervigilance? Regardless, I'm a lot more likely to run into any of the above before I see a pending PICA infarct.

Remember the Zones of Head chart? Point being, it's not just the VAD that's a visceral problem walking through the door with a somatic-like presentation.

Quote:
I'm concerned about the "accidents waiting to happen" for which there is no clinical test to reliably screen, i.e. those with hypoplastic vertebral arteries, who are at inherent risk of an initial injury from upper cervical manipulation.
I get what you are saying, but being overtly concerned about " accidents waiting to happen" is not the way to practice. Personally, I think it would drive one crazy.

I see a lot of patients with neck pain. Statistically (depending on who you read), anywhere between 25% and 70% will have a hypoplastic vertebral artery, usually left for whatever reason. Is that a concern of mine during an initial evaluation? Yes. Does it mean I'm going to avoid the c-spine entirely? No. It depends on subsequent History and physical examination findings.

Quote:
What about the patient who routinely gets his upper cervical spine manipulated due to chronic HA or neck pain who then after 10 or 20 years of forming plaques and small blockages in the VAs in part due to small intimal tears finally suffers a posterior circulation stroke and dies?
Correlation does not mean causation.

Although the morbidity is high, death from ischemic PCA stroke is rarely fatal.

Quote:
Do you think this is a plausible scenario?
Yes, it's also plausable a 10-20 yr. cervicalgic migraineur throws a clot from the heart.

Quote:
If so, what are the ethical obligations of the provider?
Simple. If you can help them, tell them. If you can't tell them. I think this is self-evident and goes without saying.

Quote:
What should be the elements of "informed consent" with regards to upper cervical manipulation? Do you think providers of this treatment should inform their patients that they may sustain damage to their VAs and that this could lead to deleterious consequences in the near or long term?
Informed consents vary but mine is, I like to think anyway, very detailed and lists VBI's, rib fractures, disc herniations, etc. This is filled out by every new patient, and reviewed/resigned on a yearly basis with established patients.

To the best of my knowledge, this is standard. I don't know any providers (DC's) that don't have patients sign an informed consent.

For the life of me I don't know how you can protect yourself from "deleterious consequences" in the long term.
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Old 02-12-2009, 04:06 AM   #22
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Hi John,

You can never, 100% of the time, rule anything out or in with clinical tests. So, there will always be doubt, which is a good thing. You should approach the C-spine with a lot of trepidation and only manipulate in select cases. Remember, mobilization at end range of rotation has not been proven to be safer than manipulation.

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Old 02-12-2009, 05:40 AM   #23
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Quote:
Remember, mobilization at end range of rotation has not been proven to be safer than manipulation.
I am not aware of deaths following low velocity mobilisations, are you?

I am aware that manips in the C-spine have not been proven more effective than mobs yet. So why take the risk ? Since I don't actually believe, for instance, in a C1-2 fixation/subluxation (in the chiropractic and manual therapist sense), then I don't intend to do a thrust in the C-spine if it's mostly for a neurophysiological effect that is probably achievable in some other, less risky, way.

But that is just me. Someone did filed a complaint against me, once, for far less than a manip. I was exonorated, but still, it changes one's perspective. I would not want the Syndic to dig in my files after an adverse effect 2dary to a c-spine thrust, even a small one, that resulted in a complaint. It is just not worth it both for the patient and me.
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Old 02-12-2009, 05:49 AM   #24
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Quote:
Remember, mobilization at end range of rotation has not been proven to be safer than manipulation.
No one's "proven" that parachutes prevent death from jumping out of planes either.

I don't like approaching my patients with trepidation. I'd rather feel confident that I might not kill or permanently disable them.
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Old 02-12-2009, 03:25 PM   #25
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Quote:
I am not aware of deaths following low velocity mobilisations, are you?
John brings up a valid point. People stroke turning their head to back out of the driveway, leaning back to get their hair washed and sneezing to name a few. Are these types of antecedent events drastically different from a graded mobilization?


Quote:
Since I don't actually believe, for instance, in a C1-2 fixation/subluxation (in the chiropractic and manual therapist sense), then I don't intend to do a thrust in the C-spine if it's mostly for a neurophysiological effect that is probably achievable in some other, less risky, way.
When there is an atlanoaxial fixation, you don't need to thrust. In my experience, the joint 'releases' (for lack of a better word) before you approach end-range.

I agree with you regarding the neurophysiological aspect. Nowhere in the human body is muscle spindle density greater than the suboccipital musculature.
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Old 02-12-2009, 03:35 PM   #26
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Are these types of antecedent events drastically different from a graded mobilization?
You mean other than they weren't caused by a health care provider?
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Old 02-12-2009, 04:21 PM   #27
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You mean other than they weren't caused by a health care provider?
John I'm going to lay out a little scenario for you.

Sally Housecoat visits her DPT with c/o neck pain and headache. Unbeknownst to both provider and patient, it's a pending VAD.

DPT applies 'graded mobilizations' to Sally's neck. She strokes.

My questions to you.

1. Did the DPT cause the stroke?
2. Was the event in progress prior to her walking in the door?
3. Would she have stroked anyway?


BTW, good luck trying to explain to a jury that you were 'mobilizing' and not 'manipulating'. Especially if there was any type of cavitation above L5. "He cracked my neck" is exactly what Sally is going to tell 12 of her peers.
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Old 02-12-2009, 05:20 PM   #28
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I get your point. Your scenario is possible. Yet, again, I've never seen a report of such a scenario. I would think, although possible, your scenario is less likely to happen with a mobs than with a manip. I think I would be able to make a Jury understand the difference between thrusts and non-thrusts technics, especially in the C-spine.

I agree that some patients are just accidents waiting to happen. But, I like the idea of decreasing my risk of being the one providing the last push needed before the fall.
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Old 02-12-2009, 05:54 PM   #29
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Seems to me that velocity is a factor. Turning the head suddenly or quickly (jerking) or having velocity applied (more jerking). Why does no one seem to consider velocity in the context in VAD or CAD?
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Old 02-12-2009, 06:46 PM   #30
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I get your point. Your scenario is possible. Yet, again, I've never seen a report of such a scenario.
I mentioned this scenario for a few reasons.

1. Ms. Housecoat with the undiagnosed VAD is just as likely to walk into her PCP's office as she is her DC's, complaining of neck pain and headaches.

2. As PT's continue to gain direct access and move towards the DPT designation, these types of patients are going to come through your door with increasing frequency.


Quote:
Why does no one seem to consider velocity in the context in VAD or CAD?
How many people stroke after a fender bender? After being tackled on the 15 yard line? Not many. If velocity were a major factor, you'd see more.

Last edited by Diane; 02-12-2009 at 07:40 PM. Reason: Sorry, no editing was done. I meant to hit the quote button instead.
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Old 02-12-2009, 06:50 PM   #31
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Seems to me that velocity is a factor. Turning the head suddenly or quickly (jerking) or having velocity applied (more jerking). Why does no one seem to consider velocity in the context in VAD or CAD?
I think velocity + extremes of rotations are the main factors and the main issu I have with most osteocinematic manips using inertia and the rapid acceleration, thus high velocity, of the applied rotationnal force.

If you apply a slow force on a structure, it will have time to disperse its force on a greater number of structure so the target structures will sustain a smaller amount of the applied force. I concede that it will sustain that force longer. But there is still control over that force and it can be stopped at any time.

On the other end, if you apply a very swift force, less dispersion of the force will be possible and the structure will sustain a greater % of the force. Not to mention the fact the CNS will have little chance to react to the force. And also, it can't be stopped once applied. But it is of a very small duration.

Try this at home :

take a banana with 2 hands very close to the center, with the convexe side facing you. Now thrust the banana by extending the elbows and by an ulnar deviation. The banana's outisde layer will break very cleanly and the banana will split in two but will otherwise stay intact.

Now take a 2nd banana and apply a slow force gradually increasing to a force similar to the one in the thrust : You won't be able to tore the yellow layer, if you do, it won't break completely. The force will disperse and you will squish the inside of the banana. The force was the same, yet the outside layer resisted.

Same thing with a vertebral artery : swift force with excess rotation and no chance for the arterial membranes/layer to deform. Slow force with less rotation : a greater chance for the artery to deform and stretch and it allows the therapist to stop whenever he wants.

Same thing happens in karate when one tries to break a pile of brick.
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Old 02-12-2009, 07:18 PM   #32
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Luck, as PTs we have had direct access since 1993 here in Ontario. Not one case described or reported with regards to this type of incident in PT-clinics. As far as I can tell.....
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Old 02-12-2009, 07:41 PM   #33
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That's a strong analogy Frederic.

LB,
I don't see how accidental events that lead to stroke are comparable to ones that occur at the hands of a health care provider.

Also, to compare the forces from a fender bender or a football tackle to that applied to the upper cervical spine during a manipulation is a stretch to say the least. There may or may not be similar velocity components, but force is a multifactorial vector quantity (F=mass x acceleration).

You're also making a lot of assumptions with regards to population characteristics. Certainly individuals involved in tackle football aren't representative of people who get their necks manipulated. The fender bender group-maybe, but still to base your reasoning on the rarity of strokes in the fender bender population has many flaws.
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Old 02-12-2009, 07:43 PM   #34
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Originally Posted by Luckbox View Post
I mentioned this scenario for a few reasons.

1. Ms. Housecoat with the undiagnosed VAD is just as likely to walk into her PCP's office as she is her DC's, complaining of neck pain and headaches.

2. As PT's continue to gain direct access and move towards the DPT designation, these types of patients are going to come through your door with increasing frequency.




How many people stroke after a fender bender? After being tackled on the 15 yard line? Not many. If velocity were a major factor, you'd see more.
I know you are from Planet US, but here in Canada, PT is autonomous and direct access, and you are talking with one or two of us, so what makes you think that people like this would not already be as large a proportion of our caseload as they are of yours?

I still think velocity should not be dismissed before being ruled out. Also, repetition. Also repeated velocity, whether by self or by other.
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Old 02-12-2009, 11:40 PM   #35
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About repetition,

Many of the cases were manips are tought to have played a role in strokes, the chiropractor had often manipulated the patient more than once in the c-spine. I can think of the last death in Quebec in 2003. In a 2 weeks period were the women started to have VBI symptoms her chiro manipulated her C1-2 at least 4 times even as she complained of symptoms analogous to VBI. The patient kept going despite the symptoms worsening until she finally had a stroke on the chiropractor table after a C1-C2 manip.

The autopsy revealed a disected vertebral artery. The coroner and the court both came to the conclusion the stroke was caused by the repeted manips done despite contraindication in the patient subjective assessment. I don't recall if the VBI test was done prior to the manips.

The chiropractor was acquitted in court because it was ruled an accident (no intent to kill) but he was radiated for 2 years by the Quebec chiropractic college.

The chiropractor was obviously careless. It could be argued he did not follow the set of rules leading to the use of the Cx manip. Yet, we all have bad days, and we all miss some of our patients signs or symptoms from time to time. So total abstinence is always the best protection.

I would like to add that in the litterature there is no report of strokes following a C-spine manip done by PT's. Could be because we seldom use it compared to others or could be because there is a lot less rotationnal forces involved in the majority of our manips.
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Old 03-12-2009, 12:31 AM   #36
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Unfortuately the tackle football analogy may apply. Lots of problems with young football players and concussions/brain damage. Brain damage even in teenage football athletes with no hx of concussions.
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Old 03-12-2009, 12:34 AM   #37
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Smith,
Do you have some references on the epidemiology of VAD in football players? Concussion is a different matter altogether.
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Old 03-12-2009, 08:45 PM   #38
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John;

Our knowledge of what happens in concussions is limited, let alone know what's happening at the VA. The last research I read stated "there was blood vessel and neuron damage in the critical brainstem region that controls balance." www.medicalnewstoday.com/articles/162876.php Seems like it's getting close to the VA. If you ask me.
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Old 03-12-2009, 10:23 PM   #39
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That's interesting, smith. But I still don't see how concussion is comparable to a rotatory upper cervical spinal manipulation. There's a lot more going on than just a quick jerk of the neck- see for yourself:



I'd say that's high velocity, high amplitude, high impact.
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Old 04-12-2009, 12:00 AM   #40
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Several posters have echoed inaccuracies. I am bunching them in my post of two parts.


Myth #1(collectively posted by):
Bas posts: >>"Not one case described or reported with regards to this type of incident in PT-clinics. As far as I can tell..... "<<

This is inaccurate. See study below.

Karma44 posts: >>"I would like to add that in the litterature there is no report of strokes following a C-spine manip done by PT's...."<<

This is inaccurate. See study below.

Karma44 posts: >>" Could be because we seldom use it compared to others or could be because there is a lot less rotational forces involved in the majority of our manips."<<


What would be your source for this assertion? From the PT manips I have observed, I am compelled to strongly disagree(re: rotation).

Where/How did y'all come to believe this?


http://www.ncbi.nlm.nih.gov/pubmed/1...?dopt=Abstract


From just reading the title or the abstract, a reader would NOT KNOW THAT:
14% of the cases in this study were manipulated by physiotherapists, however, DO take note of the misleading title of the paper: "Vertebral artery dissections after chiropractic neck manipulation in Germany over three years." WOW!! This then gets cited, referenced, and incoporated into other papers.......and so on...and so on....... perfect example of how unsubstantiated rumors start(or in this case of PTs......don't start)!

A perfect example: - Harriet Hall has been made aware of this, and additionally, other egregious errors she has penned in her editorials....YET.... She irresponsibly fails to correct accordingly thereby knowingly allowing the misinformation to be passed on.
~~~~~~~~~~~~~~~~~~~~~~~


Myth #2 (Collectively posted by):

Giovann PT: >>"If there is any doubt at all, then we should not be manipulating the C-spine, that's the bottom line."<<

Karma44: >>"I've never seen a report of such a scenario. I would think, although possible, your scenario is less likely to happen with a mobs than with a manip. I think I would be able to make a Jury understand the difference between thrusts and non-thrusts technics, especially in the C-spine.
I agree that some patients are just accidents waiting to happen. But, I like the idea of decreasing my risk of being the one providing the last push needed before the fall. "<<

THIS study found otherwise:

http://www.ncbi.nlm.nih.gov/pubmed/1...m&ordinalpos=1

Manual therapy for the cervical spine and reported adverse effects: A survey of Irish Manipulative Physiotherapists.

The most serious adverse effects were associated with non-HVTT(non-thrust)
........Which debunks the myth that the "danger" is in the thrust. In fact, adverse events were more frequent in the non-thrust group studied.
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Old 04-12-2009, 12:50 AM   #41
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ummm, you show a few inaccuracies yourself: my statement was about direct access - in ONTARIO:
Quote:
Luck, as PTs we have had direct access since 1993 here in Ontario. Not one case described or reported with regards to this type of incident in PT-clinics.
Which had nothing to do with PTs in Germany. Or Ireland. Or chiros in Germany.
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Old 04-12-2009, 04:12 AM   #42
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ummm, you show a few inaccuracies yourself: my statement was about direct access - in ONTARIO:


Which had nothing to do with PTs in Germany. Or Ireland. Or chiros in Germany.
Bas posts: >>"Luck, as PTs we have had direct access since 1993 here in Ontario. Not one case described or reported with regards to this type of incident in PT-clinics. As far as I can tell..... "<<

I read your post as having two topics....1) direct access in Ontario and 2) incidence of PT-related VAD.

Are you saying your post("type of incident") was NOT addressing PT-related VAD?(the topic being discussed in #30)

If so- I apologize for misunderstanding your post.
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Old 04-12-2009, 05:35 AM   #43
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OK, let me say it this way: the argument was that direct access would be a potential cause of increased risks for PTs for this type of incident. Thus the direct access in the first sentence introduces the content of the second - direct access does not seem to lead to increased numbers of this type incident.

Phew. It seemed logical in the context of the thread - especially after LB's post #30
Quote:
2. As PT's continue to gain direct access and move towards the DPT designation, these types of patients are going to come through your door with increasing frequency.
my bolds
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Old 04-12-2009, 06:21 AM   #44
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Nene. I have to take issue with this study's methodology. Let me highlight some of my concerns from the abstract alone.

Quote:
The purpose of this study was to determine the use of manipulation and mobilisation by the Chartered Physiotherapists (CMPT) in Manipulative Therapy Ireland and to describe adverse effects associated with the use of these techniques. A 44 item postal survey was sent to all 259 members of the CPMT (response rate 49%, n=127). All 127 respondents used non-High Velocity Thrust Techniques (HVTT) and 27% (n=34) used HVTT. Nine percent (n=12) used HVTT on the upper cervical spine. Twenty six percent (n=33) reported an adverse effect in the previous 2 years. The adverse effects were associated with the use of HVTT (4%, n=5), non-HVTT (20%, n=26) and cervical traction (2%, n=2). The most serious adverse effects were associated with non-HVTT and included 1 drop attack, 1 fainting episode and 1 Transient Ischemic Attack (TIA) 4 days post treatment. Fifty three percent (n=18) of HVTT users and 40% (n=44) of non-HVTT users reported carrying out a vertebrobasilar insufficiency (VBI) assessment.The study shows that VBI assessment may not detect every patient at risk of adverse effects. Large scale studies to investigate the risk of serious adverse reactions are needed. A system of reporting adverse effects on a routine basis could be considered.
I will look at this study, but right off the bat I see major issues here. Was this a prospective design? I can't remember what I had for breakfast three days ago, yet 129 physios are expected to reliably say how many adverse events they witnessed over the last two years? If the data were prospectively gathered I might feel better about making an inference. Secondly, the adverse events as documented by the physio right? How about a confirmed medical diagnosis of arterial insufficiency? I'm sure there are other issues which the authors acknowledge in the conclusion of the study, BUT I think this is hardly strong evidence to suggest that any danger to cervical thrust techniques is "mythical".

I think its quite real. Rare but real.
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Old 04-12-2009, 04:24 PM   #45
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Karma44 posts: >>"I would like to add that in the litterature there is no report of strokes following a C-spine manip done by PT's...."<< Maybe you are right, because what I really meant was stroke that lead to death. But I second Rod's comment about your article

This is inaccurate. See study below.

Karma44 posts: >>" Could be because we seldom use it compared to others or could be because there is a lot less rotational forces involved in the majority of our manips."<<
I can tell you that in the candian program of manipulative therapy supervised by the CAMT and approuved by the IFOMT, we use almost no osteocinematic manips in the c-spine and the manips alway imply a specific level + a locking with as little rotation as possible. Most of the manips are done with a glide force. I will also strongly stand on my comment that PT's do a lot less c-spine manips than chiropractors.

I will read your 2nd article and will come back to you
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Old 04-12-2009, 06:38 PM   #46
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Nene,

Thanks for your comments. I read your 2nd article. 4 PTs are in the liste of praticionners that ultimatly lead pts to be seen in the hospital for stroke like symptoms. It is not mentionned what was the diagnostic and subsequent consequence for the specific patients seen by those PT. So this is still no proof that anyone died because of a PT manip.

But this is beside the point. I honestly don't care if it's a chiro (wich I don't know if you are since you did not present yourself in the forum) or anyone else who provided the manips leading to the stroke. My opinion is that manips in the c-spine have a risk/benefice ratio that doesn't justify it's application for the time being. I did made an error as to the fact stroke happened because of PT's. Still haven't seen a death report though. I DID NOT READ EVERY ARTICLE. I assume you did not either. I do not do C-spine manips and probably never will even though I have learned the technics and have the qualifications to do them.

As for the relative risk of mobs vs manips, I read your Irish study. Of interest, more of the adverse effects happened after mobs, but a lot more mobs were done since the PTs doing manips were fewer. And, generaly speaking (in canada-quebec at least) manips in the c-spine are seldomly used as compared to a mob, even by a PT doing manips. So it is difficult do do a comparison on a simple retrospective plan. It would need to be done by a number of time the technic is delivered rather than by the % of occurence/amount of time since the manips may have been done very rarely even by the group who did use the manip.

For instance, one could compare PT's doing no manip, only mobs to a group of chiro that manip the c-spine every visit. I'd like to see that study done.

But I get your point, it is not known for sure if mobs are safer.

I stated my opinion on that, saying I THINK, as even the litterature can't seem to agree very much on this issu. Probably, in part, because there is a lot of bias issues.

Nene, you are welcome to say hi to every one in the Welcome forum
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Last edited by Frédéric; 04-12-2009 at 08:02 PM.
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Old 04-12-2009, 07:51 PM   #47
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I would suggest this article on the possible causal relationship between c-spine manips and VAD/strokes

Does Cervical Manipulative Therapy Cause Vertebral Artery
Dissection and Stroke?


see the article here
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Old 04-12-2009, 08:14 PM   #48
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Kharma 44 posts:

"But I get your point, it is not known for sure if mobs are safer.

I stated my opinion on that, saying I THINK, as even the litterature can't seem to agree very much on this issu. Probably, in part, because there is a lot of bias issues."

Thank -you for your kind and considered reply. I think you DO get my "point" in every and all aspects!! It's been a pleasure Kharma!.
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Old 04-12-2009, 10:39 PM   #49
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Nene,

You are welcome, the offer for an official presentation in the welcome forum is still on !

welcome

We try to treat our new participants kindly
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Old 04-12-2009, 10:53 PM   #50
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From my perspective as a HS athletic trainer Nene: the kids who get the manips seem to get worse not better. More neck stiffness etc.
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