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.
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