PROTOCOL FOR PRE-MANIPULATIVE TESTING OF THE CERVICAL SPINE This document is based on the Australian Manipulative Ther­ apist Association’s Protocol for Pre-Manipulative Testing of the Cer­ vical Spine and has been collated by the Manipulative Therapists’ Group o f the South African Society of Physiotherapy (MTG). Addi­ tions to the original text are indicated by asterisk signs. INTRODUCTION MTG is concerned about the safety of manipulation and mo­ bilisation techniques as applied to the cervical spine. Although inci­ dents o f trauma to the Vertebral artery after manipulation of the cervical spine by physiotherapists are very rare, even one incident is obviously undesirable. INCIDENTS AND ACCIDENTS OF CERVICAL MANIPULATION 1947-1986 The 58 cases o f vertebrobasilar complications following cervical manipulation gleaned from a review of the English language lit­ erature are briefly summarized. Complications reported were predominantly following chiro­ practic manipulation. O f the 54 cases in which details could be determined, manipulation was performed in 44 cases by chiroprac­ tors, in 4 cases by osteopaths, and in 2 cases each by medical practi­ tio n ers, physical th e ra p ists, and u n tra in e d personnel. T he complications were experienced by young adults (mean age 37.3 years, range 7 to 63) who often underwent multiple manipulative procedures at the incident session, not infrequently had warning symptoms or signs of potential vertebrobasilar insufficiency (VBI) prior to the manipulation session (16 cases), and had early onset of neurologic symptoms which progressed to permanent deficit or death. In 45 cases, the neurologic symptoms developed within minutes o f manipulative thrust techniques being applied. The most frequent description was of a rotation manipulation. This occurred in 29 out o f 32 cases in which the direction was specified. Pre-manipu- lative dizziness testing was reported in only one case. Grant (1988)* VERTEBROBASILAR INSUFFICIENCY Manipulation o f the cervical spine is potentially a dangerous procedure because of the spine’s intimate relationship with the ver­ tebral artery together with the possibility o f congenital anomalies and pathology which cause instability of the upper cervical spine. As a consequence there are several contra-indications to manipulation of the cervical spine. It is not the intention of this document to present a list of contra-indications to cervical manipulation. Rather, the topic is con­ fined to pre-manipulative testing for possible vertebrobasilar insuffi­ ciency (VBI). Doziness is commonly the first symptom o f VBI and its presence necessitates careful screening before any manipulative pro­ cedure is undertaken. However, complications o f VBI have arisen following cervical manipulation o f patients with no prior VBI symp­ tomatology. **It is important to be aware of the whole VBI Syndrome. The Vertebrobasilar vessels are the vessels supplying the brain stem, and occipital lobe and thalamus and even part of the temporal lobe. Symptoms relate to the structures supplied by these vessels. If any branches are compromised, appropriate symptoms result. The groups o f structures supplied cause specific symptoms and signs. i) Occipital lobe: temporary or permanent blindness, homony­ mous hemianopia or fortification spectra (zigzag lines, spots, stars etc.) may suggest occipital ischaemia via the posterior cerebral a r­ teries. ii) Cerebellum and vestibular nucleus connections: in5i!)D- ciency to these areas causes dizziness but may also cause nystagmu*, vertigo, ataxia, intention tremor, dysarthric speech or various co-or­ dination problems without dizziness. iii) All cranial nerves in the brain stem e.g. Ill, IV, VI may cause double vision or pupillary changes V may cause sensory loss or facial pain VII may cause facial paralysis VIII balance or hearing loss IX & X swallowing or speech problems XII tongue movement and articulation problems iv) Long tra c t involvement of all fibre tracts conveying infor­ mation between the cortex and spinal cord i.e. single arm and leg or any combination of unilateral, bilateral or contralateral arm and leg disability in terms o f power, reflex, pin prick, light touch, position and vibration sensory loss. Although dizziness is commonly the presenting symptom of VBI, it must be remembered that it may not be present, whereas other symptoms may well exist and would also contra-indicate man­ ipulation. It is important to remember that it is not only manipulation which is potentially harmful. Mobilisation techniques, especially at the end o f range, can be similarly harmful** The procedures outlined in this protocol should ensure that physiotherapists exercise responsibility in using the effective manipu­ lation techniques at their disposal. However, it must be remembered • that an element o f unpredictability remains and incidents do occur even when all pre-manipulative tests are negative and even when the patient has responded favourably to manipula­ tive treatment in the past • that the test procedures themselves hold certain risks • that it is important to record carefully and accurately all dizzi­ ness tests and pre-manipulative testing procedures undertaken and the responses to them on the part o f the patient • that even when the patient is made aware o f the risks attached to a manipulative procedure, that is, informed consent is ob­ tained, the physiotherapist may still remain legally liable if rea­ sonable care, that is the care expected o f the average, competent and prudent practitioner, is not employed. OUTLINE OF PROTOCOL Subjective Examination All patients with upper quadrant dysfunction should be ques­ tioned regarding the presence of dizziness and other symptoms sug­ gestive o f vertebrobasilar insufficiency (VBI). Such symptoms include light headedness, strange sensations in the head, dysaittaria, diplopia, drop attacks, blackouts, disturbances of vision, tinnitus (see Section II). Physical Examination Patient Category: • Basic pre-manipulative testing is required for patients who do not complain of dizziness and who respond negatively to specific questioning, (see Section n b ) Choice of techniques and method of application • Cervical manipulation is contra-indicated for patients who have dizziness and other symptoms suggestive o f VBI and whose Physiotherapy, February 1991, vol 41 no 1 Page 15 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) tests produce or reproduce dizziness and/or associated symp­ toms. • Cervical manipulation is contra-indicated for patients who ex­ perience dizziness provoked by cervical movement during or after techniques o f examination or treatment. • For patients who present with dizziness and/or other symptoms o f possible VBI origin but whose tests are negative - any technique which provokes dizziness must not be used. - passive mobilising techniques should be used in initial treat­ ments and their effect over a 24-hour period known before it is even considered that manipulation be used. - should progression to manipulation be required, a single gentle manipulation may be used providing all the tests described in Section Ila and lib are negative (see later). • In any patient requiring cervical manipulation: - a generalised rotary manipulation of the cervical spine is dangerous and must n o t be used - the use of strong axial traction during a manipulation should be avoided as it is likely to increase the risk o f injury to the vertebral arteries - at the first treatment session in which manipulation is used, a single (not multiple) gentle manipulation should be per­ formed - dizziness testing in the simulated manipulation position should be performed at a ll subsequent treatm ents (not just at the initial consultation) in which the physiotherapist wishes to use cervical manipulation. Recording Physiotherapists should always accurately record the dizziness tests undertaken and the patient response to each test, (see adden­ dum for suggested format).**The MTG strongly advises physiother­ apists to keep this evidence.** **lnforming the Patient The patient should be informed as to the “nature” o f the manoeuvre that will be performed. If the vertebral artery test is positive, the patient should be advised accordingly and warned against any forced manipulative procedure which involves the cervical spine at that stage. This would not exclude manipulation at a later stage should there be no evidence of vertebral artery insufficiency on retesting.** DETAILS OF THE CLINICAL EVALUATION In any patient for whom treatment o f the cervical spine is to be undertaken, the presence or development o f dizziness, or other symp­ toms o f possible vertebrobasilar insufficiency (VBI) is carefully as­ sessed. The four stages are: - subjective examination - physical examination - symptoms provoked during treatment of the cervical spine - symptoms/oZfovwig treatment. SECTION I: SUBJECTIVE EXAMINATION In every patient presenting with upper quadrant dysfunction, questioning is specifically directed to elicit the presence of dizziness. Should the patient suffer from dizziness then questioning proceeds further and must reveal • the type, degree, frequency and duration o f the dizziness, the occurrence, or aggravation of dizziness by head movements and by sustained positions of the head and neck, particularly rota­ tion, extension or combinations o f these movements. Any other movement or posture volunteered by the patient is also re­ corded • the nature and type of any symptoms associated with the dizzi­ ness, for example, light headedness, strange sensations in the head, dysarthria, diplopia, dysphagia, drop attacks, blackouts, disturbances o f vision, tinnitus • the history o f dizziness vis a vis the history o f the neck, headache or other symptoms • the status of the dizziness; is it improving, worsening or staying the same? • previous treatment (if any) and its effect in relieving, exacerbat­ ing or producing dizziness and/or associated symptoms. “ Although dizziness is commonly the presenting symptom of VBI, it must be remembered that it may not be present, whereas other symptoms may well exist. Questions must also be asked to elicit presence o f other symptoms, which would also contra-indicate man­ ipulation.** (See “VBI Syndrome”) SECTION II: PHYSICAL EXAMINATION Ila: Basic Pre-manipulative Scanning of Patients without Dizziness; Standard Routine Tests Sitting and/or supine lying (if tests are +ve in sitting, no need to repeat in lying): • sustained extension • sustained rotation to the left and right • sustained rotation with extension, to left and right • simulated manipulation position. Here the patient’s head and neck are held in the manipulation position as a sustained pre- manipulative procedure. The patient is questioned regarding dizziness and any other symptoms both during each test and after each test position has been released. The therapist also observes the eyes for nystagmus. Each test position is maintained with over pressure for a minimum of 10 seconds (or less if symptoms are evoked) and upon release, the therapist needs to be aware that latent responses can occur. Recent research suggests that this minimum time may be insufficient to elicit VBI symptoms. Routine physical examination o f the cervical spine will take the patient’s neck to the end o f the available physiological ranges of extension and of rotation with over pressure applied. However, in patients where these movements are restricted by pain and stiffness, fu 11 range cannot be obtained and such compromises as may be placed upon the vertebral arteries may not occur. In such cases a manipula­ tion may not be performed. lib: Additional Tests to be Undertaken for Patients who Present with Dizziness • testing the position or movement which provokes dizziness as described by the patient • quick movement of the head through the available range of movement when the patient relates dizziness to quick move­ ments of the head rather than head posture or positions • when dizziness is provoked upon rotation, either during sus­ tained postures or repetitive motion, these tests are further explored in the standing position in order to differentiate dizzi­ ness arising from the vestibular apparatus o f the inner ear from that caused by neck movement: head held still, sustained trunk rotation to left and right; or head held still, repetitive trunk rotation to left and right • sustained positions are adopted for a minimum o f 10 seconds or less if symptoms are provoked. These tests when positive, suggest that the patient’s dizziness is not caused by inner ear labyrinth disturbance. lie: Summary Cervical manipulation is contra-indicated when any VBI test is positive, that is, a test produces or reproduces dizziness and/or asso- Bladsy 16 Fisioterapie, Februarie 1991, deel 47 no 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) dated symptoms. Manipulative procedures are contra-indicated if dizziness and/or associated symptoms are provoked whilst adopting a treat­ ment position, during a treatment technique or following a treatment technique. The treatment technique provoking such symptoms is also then contra-indicated. Patients should be warned o f the dangers of manipulation of their cervical spine. ** A manipulative technique may be conducted if VBI tests are negative and no contra-indications to cervical manipulation have been elicited on specific overall assessment.** References * Grant R (1988) Dizziness Testing and Manipulation of the Cervical Spine. Clinics o f Physical Therapy. Vol 17,7,111-124. Chur­ chill Livingstone. New York. ** The Manipulative Therapists’ Group o f the South African Society o f Physiotherapy. Acknowledgements 1. Australian Journal o f Physiotherapy 1988; 34(2):97-100 for permission to use and print extracts from their Protocol. 2. Professor Vivian Fritz, Department of Neurology, University of the Wit- watersrand for her advice V - ADDENDUM: PRE-MANIPULATIVE DIZZINESS TESTING Date: Patient's Name: Subjective questioning dizziness yes no other possible VBI symptoms yes no type: Physical tests Dizziness with sitting supine yes no latent yes no latent - sustained extension - sustained rotation (L) - sustained rotation (R) - sustained rot (L)/ext - sustained rot (R)/ext - supine, sustained manipulation position - other position or movement nominated by patient - quick rotation (L) - quick rotation (R) - quick other movements - standing head held still, trunk rotation (L) - labyrinth yes/no trunk rotation (R) - labyrinth yes/no PHYSIOTHERAPISTS WORK IN THE UNITED STATES We handle all Licensure and Visa paperwork. Minimum commitment of one year required. 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