Should we abandon positional testing for vertebrobasilar insufficiency?

[Steven Lagasse]

Short article – give it a read.

Do you use VBI testing in your clinical practice? If so, why? If not, why?

It would be great to gain some rationale from the mentors as well!

Thanks, everyone.

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[Eric Magrum]

Great post – authors to be familiar with (especially for this topic).

Well discussed points with recommendations for additional evidence.

How would you summarize what we discussed regarding screening/clearing in this region from Weekend 1?

How does this paper add to your clinical decision making with patients who your are going to treat the upper cervical spine?

[Michael McMurray]

I have evaluated/treated a few patients with vertigo where I have assessed for VBI before performing the canal repositioning technique. I figure this is a good way to not only assess VBI but also take/talk them through most of the positions of the test before we perform it at a faster speed. While the CRT does not place the patient in to full rotation and extension, I prefer to test the positions before adding in the speed/velocity of CRT.

In regards to assessing before cervical manipulation, I cannot say that I have evaluated for VBI as I have not performed any and feel more comfortable at this point focusing more on CTJ or thoracic manipulations.

I think the subjective report from the patient is a huge part of screening for VBI as you can ascertain a lot of information by asking about specific symptomatic positions such as shaving ones face, looking up/overhead into cabinets, if they rest their head on the hands, etc. Along with that is their description of symptoms (“HA like no other”) and asking about dizziness, difficulty swallowing, speech difficulties, nausea, for example. in addition to the subjective report, increasing the stress gradually and providing progressive overload while assessing for symptoms is at this point the best way to objectively help rule out potential red flags and help guide us to perform or not perform manipulation to the cervical spine and be more cautious.

The big take away from this article aside from the amazing citations and research is the ending of “no added value to the patient evaluation” section:

“Screening for the effect of head movement on vascular haemodynamics and adequate collateral cerebral blood flow therefore may still be an important part of the evaluation of the patient (Blanpied et al., 2017) and relevant to physiotherapy management. In addition the tests can be quickly incorporated into an active movement assessment and do not add substantially to the assessment time.”

While, at this point we can’t use these tests alone to rule in/rule out VBI, we can use these tests, in my opinion, to progressively overload the system. In doing so we can gather information in the evaluation, whether it be the patient becoming symptomatic and to avoid those movements and potentially refer or that the patient is able to tolerate specific loads, which we can use in our future treatment/interventions.

I also think the authors provide a good point that positional testing is not unique to VBI and that there are other diagnoses which may be related to the positional testing such as vestibular or cervicogenic as well.

Finally, the authors also did a good job of stating what needs to be done in order to better assess VBI testing. They not only talked about both sides of the argument to discard testing or leave it in the evaluation but they provided us with a potential groundwork in order to better research this topic:

“…future studies must use appropriate dynamic imaging
i.e. angiography or transcranial Doppler in different head positions,
to capture the most informative images at the most relevant sites.
The downstream effect of rotated head positions on blood supply to the
brain needs to be evaluated in symptomatic rather than asymptomatic
individuals and in those with confirmed vascular pathologies. In tandem
there is a need for detailed characterisation of the timing and nature of
symptom responses to the positional tests in those with vascular pathologies,
healthy individuals, and those with other causes of dizziness,
for a full understanding of their clinical interpretation and diagnostic
utility.”

[helenrshep]

Nice points, Brandon. I especially agree with your idea about using the tests to progressively overload the system.

I like to view these tests as part of a bigger cluster. Yes, on their own, they are not great but this is why we cluster! Use info from the subjective, the description of their symptoms, mechanism, etc to then have a series of data points that lend support to rule in/out diagnoses. As the authors pointed out, it doesn’t add much time to do these tests so they may be worthwhile, however, at the end of the day “do no harm” is the major player in my book. We have enough ways to treat patients that don’t involve cervical mobilization/manipulation and end range techniques, that if there is even a small part of me that is concerned about VBI, I’m probably not going to go that route. Why do a risky technique when other techniques might yield the same result?

At the very basics of the test, I think it is interesting to note the effect of the Circle of Willis. We think we are restricting blood flow and looking for symptoms, however, it’s really more about the rest of the circulatory system and how well it is able to compensate.

[Taylor Blattenberger]

First of all, this was a well written article that presented information very well. I felt myself have small shifts of opinion multiple times as reading. When I review my thoughts on the test, I think how the performance and results of the test would change my treatment route with a patient.

If performed and positive for symptoms: Is this patient at risk of dissection, or are their other vessels not providing collateral flow? Is this even a vascular response, or is it a vestibular or cervicogenic dizziness/headache?

A negative result is even less helpful: Just because there are no symptoms, does not indicate that the vessel being loaded is healthy. They could still be at a higher risk of dissection.

So, as I understand it now, I’ll either get a negative and be skeptical, or get a positive and be slightly more skeptical. MAYBE a positive test coupled with PMH of vascular disease and other subjective reports would push me even further from a technique, but I cannot see myself using this test to make myself more comfortable with performing a technique that would be potentially compromising.

[awilson12]

A few take aways for me from this article:
– the importance of differentiating VBI vs CAD- the “scary” reports out there from manipulation are often in patients with artery dissection (at least that’s my understanding) and this article points out that these patients really should be identified from a good subjective history & there is no utility in these types of test in this population
– VBI is a result of multiple artery occlusion to the point that the collaterals don’t have the capacity to make up for lack of blood flow from one particular artery; I thought it was a good point to identify the weaknesses of studies assessing these maneuvers in patients only looking at single arteries

Do I perform VBI testing how it is written? No- it makes sense to me the method we discussed in the course series of progressive loading

Does this article help with clinical decision making? Yes- even with the progressive loading schema I think this article brings more awareness that this may be helpful in identifying cases of more “severe” VBI and that it may not have much utility at all in patients with dissections (I feel like previously I just grouped these differentials together and viewed it to be used for both populations)

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