vbi and cad testing

[123rich]

hi can someone tell me what the difference between vbi and cad testing is. also why it is done and what to look for in terms of signs/ symptoms. any help would be great.

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[Dr Damien]

Dear 123rich

I presume what you mean by CAD testing is Coronary Artery disease testing...
VBI is verterbrobasilar insufficiency testing...
I am not a cardiopulmonary specialist but I presume this would involve a variety of screening tests ranging from simple assessment of cardiac parameters eg blood pressure, heart rate/pulse rate to ECGs, Cardiopulmonary endurance tests...etc to ascertain cardiac function

Verterbrobasilar Insufficency tests I am well farmilar with simply because in the realm of musculoskeletal PT, we do as part of the assessment of the neck either prior to a manual intervention to the neck. It is done mainly to assess if there are any physical MSK restrictions to the blood supply to the brain...the vertebral arteries undergo a turn in the foramina of the upper cervical vertebrae...this turn means that certain neck movements especial extension/rotation/ sideflexion can potential occlude this artery. with normal anatomical limits there shouldnt be a problem...however if the artery is diseased, and/or if the foramina and/or uncinate part of its anatomy have osteophytes/ or are stenotic, this might mean they are prone to occluding this artery...causing a patient to black out or go unconscious...

there are many ways of carrying out these tests and different authors have described many protocols
one protocol is to start with neck side flexion, hold for 10 seconds both sides...the enxtension hold 10 seconds...if the client does not look like he is going unconscious(eyes rolling up etc) you can progress into doing more restrictive movements (adding rotation, extension and side flexion). This protocol emphasizes starting in the upright position...you may proceed to the supine position and carry these tests out...

the other description suggests just using the supine position and carrying out these movements holding for 30 seconds
a look of being dizzy or passing out (eyes rolling up, or closing, slow in communication) will suggest a positive VBI test. paatients should never be allowed to pass out during these tests if they are found positive

It means your manual therapy sessions to the neck should either be done with extreme caution or totally avoided...especially with movements that involve rotation

It is also on of the reasons for unexplained falls in the elderly, who say they turned round too quickly and found themselves on the floor... for these clients a vestibular assessment needs to be done and a VBI testing can be part of your neck assessment...

Unfortunately, a downside to this is, there is a risk involved in this assessment...
Patients passing out, damage to the brain, and laceration of the vertebral artery can happen during a test (these are very rare but is good to be aware) especially when there are osteophystes that are present without the therapist knowing...

Its good to request for a radiological assessment prior to an intervention of the neck when it comes to the elderly...

cheers

[123rich]

thanks for the reply. what i meant by cad testing was cervical artery dsyfunction? is that the same as VBI?

[Dr Damien]

Dear 123rich

With regards the tests, I should think they are the same...just a matter of terminology I suppose.
Cervical Artery Dysfunction would be basically any abnormality in the arteries...VBI could be one of them...
I would say they are very much meaning the same thing...
the tests i presume are the same...there are other ways to assess whether these arteries are functioning properly...but I wouldnt think there is a difference between CAD and VBI testing...

I think these terms are not meaning the pathologies exactly but the state in which they are not able to supply blood to the brain effeciently...rather than pathology they suggest cause...wherein various reasons could be put under them
1) arthritic changes
2)posture...
3) primary arterial diseases compounded by the above
4) emboli...
several order reasons, I would take my mind off pathology and see these tests to mean cause of the ineffecient supply of blood to the brain...

have i been of help or have i added to the confusion?lol

cheers

[SigMik]

Hi.

I attended a workshop with Kerry, the guy who was asked by the MACP to do a synopsis on this topic. The whole group was a bit terrified afterwards. The main issues discussed within the workshop and later on with the students on my course were something like:

- the main problem is, as Damien already recognized, the tests themselves are an equal risk as is to actual do the actual manipulation.
- the most usual test, the sustained rotation, is just a part of a whole cardiovascular assessment. On the workshop we spent 1 hour on these tests ranging from palpation of all pulses in various positions, ankle-brachial index, capillary refill, stethoscope assessment, etc. This in combination with getting an informed consent from the patient of the possible risks associated with a manip - I'll guess it'll spark some nocebo, fear (justified or not?), etc...
- what to do if the patient is on anti-coagulant medicine? Up for manip? No. The injury to the arterial wall is already done, the meds just compensate.
- what about oral contraceptives? They're associated with increased risk of venous thrombosis. Same for smokers off course. That rules out quite a lot of people.
- you have to consider the precautions, the contra-indications, the nocebo-effect, the chance you're personally willing to take, even after doing all the pre-work as above.
- chances are very high that you'll achieve quite a lot with a low velocity mobilization + exercises too.
- we couldn't really conclude on what the chiro's do in regards to these matters.
- the discussion seems to take different directions on collegial discussions, compared to what is really going on in clinics and I think this will be a never-ending story.

If I'm correct, they've also stopped teaching upper cervical manips in Australia, and I think it's not allowed for physio-specialists to do it in Canada??? Correct me if I'm wrong, good to get an update on this.

I've attached a few of the articles I've got on this, should cover everything you want to know about it. My guess is that you won't be doing manips for a while after reading them, but then as time goes by... Well.

Kind regards,
Sigurd Mikkelsen

[Dr Damien]

Dear SigMik

Thanks for those materials. The neck is definitely a scary domain for the manual therapist. I personally avoid messing with it...

The take home message from your input is even though it might seem that the elderly are most at risk, really anyone is at risk of a faulty manip, or assessment...

What i always advice is if manual therapy is to be considered and all the contraindications have been considered...better to use gentle traction first

I generally always take the hands off approach when it comes to the neck...

great articles...should print them out for ma colleagues here...

cheers

[SigMik]

Dear DrDamien. You're welcome, and I hope they'll might add something to your already wide base of knowledge. You're right on with what I tried to convey in my previous post - almost anyone are in reality in risk for complications due to a manip... Or assessment... Imagine how tensed up and un-relaxed the patient would be after the extensice CV-testing and after getting an informed consent of possible complications? Think that will cause some nocebo?? And as the articles reports, even if you've done all the pre-work due to the protocols as suggested, it's still in reality a risk... What obviously complicates it more is that the protocols indirectly (or even with that first casestudy in the first article) indicate that any assessment (not only cardiovascular screening) or work on the neck is potentially a hazard... For my part after getting through the CAD dilemma, I take an even stronger responsibility as a health care practitioner, in doing a thorough general health screening, on all patients and very aware on whom I choose to manip. But - it is important to put this into perspective as well - it's potentially dangerous to exercise too or even take a dump if you have any indications of a cardiovascular risk profile. This would probably put the manips in an even better perspective - http://www.guardian.co.uk/science/20...ncture-needles

I don't know if there's any chiro's or osteopaths in here, but it would be interesting to hear their take on this issue.

You say you're generally always take the hands off approach when it comes to the neck, what do you mean with that? I'm thinking it's a big difference in being careful and considerate when it comes to the neck and to use hands off approach. Do you ever manip the neck?

Ziggy

[Dr Damien]

Dear SigMik

What I mean by hands off is whatever can be achieved by active exercises, I would advocate that before I decide to manipulate the neck.

Maybe clarifying terms but give a better understanding so we all are on the same wavelength. manipulation is often described as the high velocity low applitude thrust that we give joints to gain range after we have reached the pathological limit. If by manipulation you mean this, then I do not manipulate the neck...I will always go for active exercises first, mobilization using traction or segmental mobs of grades B pressure... treatment can be slow but the effect is always the same as having a quick manip...

However if you mean" manipulate" as most doctors often use to describe any form of manual therapy (including massage) then I do manipulate the neck...I desist from high velocity movements only because I know the dangers. 98% of my clients are hypertensive, all of them are usually on statins, at least half of them have to be on wafarin, most of them have had some form of stroke before, anatomically the all have forward necks, and at least three quarters of them suffer from dizziness, a small percentage of them have an aneurysm somewhere, three quarters of them have heart issues and at least half are diabetic.

If the come to me with neck problems...manipulation is the last thing on my mind...i would take the hands off approach with these clients, using heat therapy as well as active exercises combined with massage to gain the same effect (it often takes forever). I would work on their postures as well with sound advice. This works for the majority and for me its safer...the most I would do if these are not taking effect would be to use grades B mobs...and I would always avoid the rotary components...This the client can do themselves...with gentle controlled and sustained traction and grades B mobs of segments, it is easier for them to completer the rotations as exercise...however because I always tell them to be wary of pain...we often get slow rehabs but usually effective...

have i ever manipulated the neck? yes, when I worked in outpatients back in my country, these clients were usually fit...and the risk for them was often very low...
Im talking military men and/or sports clients...cab drivers, office workers who sit on the computers for long hours...

Im too aware of the dangers to put the clients at risk...at the same time im too chicken to find out what could go wrong...

The other thing is often what most people may not consider...the possibilty of a latent systemic arthropathy i.e R.A, some people dont know they are beginning to have these symptoms...the danger of manipualting such necks is too great...

Cheers SigMik