Differentiation test to determine between vestibular and VBI symptoms

Differentiation test to determine between vestibular and VBI symptoms

The patient stands and rotates the cervical spine to the right and left. A note is taken of symptoms such as dizziness or nausea. Either vertebrobasilar artery insufficiency or the vestibular apparatus could cause symptoms produced as a result of this manoeuvre. In order to differentiate between these two structures, the physiotherapist fixes the patient’s head and the patient keeps the feet static and facing forwards. The patient then rotates his or her body to the right and to the left while maintaining the head in a static position. If symptoms such as dizziness or light-headedness are produced with this manoeuvre then they are a result of vertebrobasilar pathology, because the head remains still (and the vestibular apparatus will be unaffected) and the cervical spine is rotating affecting the artery.

Vertebrobasilar testing (Maitland 2001)

This test is performed in both sitting and supine positions.

1. Sustained rotation for ten seconds is performed to each side. Note any symptoms.

2. Sustained extension for ten seconds is performed. If the patient is asymptomatic then:

3. Combined rotation and extension to each side is sustained for ten seconds. Note any symptoms. A positive test would be to induce feelings of dizziness and nausea. The shoulder complex Observe full shoulder elevation through flexion and abduction for the shoulders bilaterally, because during the last few degrees of elevation the thoracic spine extends to allow for full shoulder elevation. A stiff kyphotic thoracic spine will limit shoulder elevation.

Bony anomalies

Osteophytes may be palpable at the C2–C3 facet joints in patients with pre-existing spinal pathology (Maitland 2001). Approximation of the spinous processes of C6–C7 is also a common feature.

Accessory spinal movements

With the patient prone, central pressure on the spinous processes C2–T6 and unilateral pressures on the articular pillars C2–T6 is applied by the physiotherapist, noting levels of stiffness, pain response, muscle spasm and areas of hypermobility

Passive physiological intervertebral movements (PPIVMs)

PPIVMs may be used to confirm any restriction of motion seen on active movement and to detect restriction of movement not discovered by the active movements. They are also used to detect segmental hypermobility (Magarey 1988; Maitland 2001).

Palpation

Palpate the soft tissues, noting the positions of vertebrae and myofascial trigger points (localised irritable spots within skeletal muscle). These trigger points produce local pain in a referred pattern and often accompany chronic

musculoskeletal disorders. Palpation of a hypersensitive nodule of muscle fibres of harder than normal consistency is the physical finding typically associated with trigger points (Alvarez and Rockwell 2002).

Observe for local or referred pain, thickening of structures or stiffness. Remember that anomalies of the bifid spinous processes of the cervical vertebrae and differences in their spacing are not uncommon and may not be clinically significant (Maitland 2001). Soft-tissue changes, including sub-occipital thickening and shortening in the extensors and prominence, and

thickening of the articular pillar of C2–C3 facet joints, are common in degenerative disorders. Soft-tissue changes around the cervicothoracic junction are also commonly found and may be referred to as a Dowager’s hump.