APA VBI Guidelines

Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine DisordersRevised February 2006 Authors: Associate Professor Darren Rivett Dr Debra Shirley Dr Mary Magarey Professor Kathryn Refshauge These guidelines comprise a set of recommendations regarding assessing for vertebrobasilar insufficiency and obtaining informed consent prior to the application of cervical spine manipulation and mobilisation, based on the most recent evidence. These guidelines replace the APA Clinical Guidelines for PreManipulative Procedures for the Cervical Spine (2000). The APA wishes to acknowledge Musculoskeletal Physiotherapy Australia (MPA), for the revision of these guidelines. © Copyright Australian Physiotherapy Association 2006 This work is copyright. Apart from any used permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the APA. Australian Physiotherapy Association PO Box 6465, St Kilda Road Central Victoria 8008 Australia Phone +61 3 9534 9400 Fax +61 3 9534 9199 Email: [email protected] Website: www.physiotherapy.asn.au MPA IS A NATIONAL SPECIAL GROUP OF THE APA 24. or other possible symptoms of vertebrobasilar insufficiency (VBI) should be carefully assessed in any patient for whom examination or treatment of the cervical spine is to be undertaken. Decisions on management.APA Clinical Guidelines February 2006 CLINICAL GUIDELINES FOR ASSESSING VERTEBROBASILAR INSUFFICIENCY IN THE MANAGEMENT OF CERVICAL SPINE DISORDERS Introduction The presence or development of dizziness. Physiotherapists should be aware of the following points in relation to the use of provocative testing for VBI: • The tests themselves are provocative and therefore hold some inherent risk. The provocation of symptoms or signs during testing should alert the physiotherapist to the need for particular care in the selection of examination and treatment procedures. 20. 15. There is no simple clinical method for testing the intrinsic state of the vertebral artery and physiotherapists should be cognisant of this when examining or treating the cervical spine. The aim of these clinical guidelines is to facilitate the clinical recognition of VBI by all physiotherapists who treat the cervical spine using procedures which could compromise the vertebral artery or trigger adverse neurovascular events. if appropriately selected and performed with care (including only to the initial point of provocation of symptoms). History (subjective examination) 2. the physiotherapist must also have a thorough understanding of the implications of such symptoms and signs in the management of cervical spine disorders. 31 . This document details the symptoms and signs that may be potentially associated with VBI. 12. including choice of treatment. For the purpose of these clinical guidelines. together with clinical guidelines recommended by the Australian Physiotherapy Association (APA) and Musculoskeletal Physiotherapy Australia (MPA. 20. any potential risk to the patient will be minimised. 25. and to this end a checklist for use prior to spinal manipulation21 is included for information in Appendix 1. 28. and 4. a National Special Group of the APA) for examination and treatment of all patients with disorders of the cervical spine. The document also describes the recommended procedure for provision of information to patients about cervical manipulation and mobilisation. Recent research has also identified blood flow changes in the simulated manipulation position1. 18. most notably cervical manipulation and mobilisation16. 33 . manipulation is defined as a procedure involving a high velocity thrust. 9. To ensure safe practice. A summative Clinical Flowchart for the appropriate application of cervical manipulation and mobilisation procedures involving end-range rotation is included in Appendix 2. they are primarily provided to help inform the clinical reasoning of the physiotherapist in their management of the individual patient. 15. However. 23. It is important that the physiotherapist has the knowledge needed to recognise symptoms and signs potentially associated with VBI. Key supporting references are found in Appendix 3. 4. The physiotherapist is reminded that VBI is not the only safety consideration when assessing and treating the cervical spine. During treatment of the cervical spine. 24. While the clinical guidelines are recommended. 14. Although the tests have shown mixed results in relation to changes in vertebrobasilar arterial blood flow in experimental studies10. APA Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders ©APA 2006 Page 2 of 14 . obtaining consent and the recording of these steps. whereas the term mobilisation refers to any other manual joint movement procedure applied to the cervical spine. 19. The recommended tests will not identify all patients at risk of suffering an adverse event following cervical manipulation or mobilisation. • • Assessment for the presence of symptoms and signs associated with VBI occurs at four stages in the management of a patient with an upper quadrant disorder: 1. 17. it appears that end-range rotation is the most sensitive cervical position 1. 6. The recommended tests are the most valid procedures for determining the presence of VBI and the adequacy of the collateral circulation identified in the literature to date3. 13. should be continually (re-)evaluated on the basis of the outcome of these assessments. Physical (objective) examination 3. Following treatment. tremors and sweating • Other neurological symptoms. sharp pain located in the ipsilateral postero-superior region of the neck and occiput and for which there is no past history should be regarded as suspicious8. It is therefore prudent to initially treat conservatively and carefully monitor progress. 32. orthostatic hypotension by rolling in bed rather than by head movement is typical of a vestibular disorder. other symptoms associated with VBI should be sought. however. particularly those involving rotation or extension The temporal history of the symptoms relative to the history of the patient’s complaint The status of the symptoms Any previous treatment and its effect on the symptoms. stroke and head injury may co-exist with VBI2. Some features may facilitate differentiation of dizziness or other symptoms associated with VBI from similar symptoms produced by other conditions:2. that other conditions such as vestibular disease. 5. migraine. Patients may also report a history of cervical trauma7 or neck stiffness. It should be noted. APA Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders ©APA 2006 Page 3 of 14 . severe. questioning is specifically directed to determine the presence of dizziness which is the most common presenting symptom of VBI. 5. History (Subjective Examination) In every patient presenting with upper quadrant dysfunction. Should the patient suffer from any of the symptoms associated with VBI described above. cardiovascular disease. blurred vision and transient hemianopia • Dysarthria (difficulty with speech) • Dysphagia (difficulty with swallowing) • Drop attacks (sudden loss of power with no loss of consciousness) • Nausea and vomiting • Lightheadedness and fainting • Disorientation or anxiety • Hearing disturbances such as tinnitus • Facial or oral paraesthesia or anaesthesia • Pallor. then questioning should explore the symptoms further. When nystagmus is associated with VBI. including: • Visual disturbances such as diplopia (double vision). Pain usually precedes ischaemic symptoms and signs. particularly if accompanied by nystagmus Symptoms and nystagmus that are latent. Specifically. and their neck range of motion can be restricted. including: • • • • • The type. Until the ischaemic response becomes manifest it can be difficult to differentiate a dissecting vertebral artery from a benign mechanical neck disorder. ear disease. degree. fatiguable and habituate are typical of a vestibular disorder. 11. frequency and duration of the dizziness or other symptoms The production or aggravation of the symptoms by neck movements or sustained positions. it demonstrates no fatiguability. If dizziness is present. sudden. which are usually the first symptoms of dissection of the vertebral artery.APA Clinical Guidelines Section 1. if from a low to a high position. epilepsy. with the time interval varying among individuals29. Enquiry should also determine the nature of any neck pain or headache. 32 • – • – – • Constancy of symptoms symptoms associated with VBI are rarely constant Provocation of symptoms by a change of position in relation to gravity is strongly indicative of a vestibular disorder or. rotation can be further explored in the standing position in order to differentiate dizziness arising from the vestibular apparatus of the inner ear from that arising from the cervical spine (either cervical vertigo or VBI): • For positional provocation. APA Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders ©APA 2006 Page 4 of 14 . • For movement provocation. supine lying or sitting). Physiotherapists should be mindful of this limitation to their examination and consider this information in their decision-making about treatment choice.APA Clinical Guidelines Section 2. upper cervical extension can be added to end-range rotation and sustained as described above. Physical (Objective) Examination 2. or less if symptoms or signs are provoked. Again. The physiotherapist must determine the benefit of additional testing for any particular patient based on their clinical presentation.1 Routine examination for all patients with upper quadrant dysfunction In every patient for whom treatment of the cervical spine is to be performed. 33. If dizziness or other symptoms are provoked in either of these positions (i. Provocative testing should be immediately ceased upon provocation of symptoms or signs clearly indicative of VBI. During this time.e. the vertebrobasilar system may not be adequately compromised. When symptoms are undifferentiated or unclear as to their origin. Physiotherapists should enquire about the presence of any symptoms associated with VBI and observe for any signs regularly throughout the physical (objective) examination. If dizziness is provoked upon rotation movement or sustained position and its origin is unclear. the test can be repeated in the alternative position. a period of at least 10 seconds should be allowed before proceeding with the next examination procedure. including physiological movements to the end of available range with overpressure (where applicable). This is because the vestibular system is affected by gravity so that symptoms will be different in supine lying compared to sitting. The recommended minimum testing for a patient who reports symptoms associated with VBI (but which are not clearly indicative of neurological ischaemia) comprises the following: • Any position or movement which provokes symptoms as described by the patient • Sustained end-range cervical rotation to the left and right if any cervical procedure is being considered which is equal or greater in vigour to this test25. If additional testing is required to further test for the presence of symptoms or signs associated with VBI or further test collateral circulation. Provocation of dizziness during differentiation testing suggests that it is not caused by a vestibular disorder. routine physical examination of the cervical spine must be undertaken. Physiotherapists should be aware of the potential for a latent response to movement and positional testing.2 Testing for patients who report symptoms associated with VBI during the history (subjective examination) If reported symptoms are clearly indicative of VBI or vertebral artery dissection then provocative testing is not required and medical opinion should be sought prior to undertaking any examination or treatment of the cervical spine. This will facilitate differentiation between symptoms caused by VBI and those related to the vestibular system. the physiotherapist should be mindful that the tests by their very nature can be stressful to the vertebral artery. most notably during cervical physiological and accessory movement testing. unless symptoms or signs are provoked sooner. 2. The physiotherapist should examine the patient’s eyes for the production of nystagmus while the neck is held in the sustained position and simultaneously question the patient about the (re)production of symptoms. whereas symptoms related to VBI will be essentially unchanged32. On return to neutral from the sustained position. All positions should be sustained for a minimum of 10 seconds. sustained positions are held for a minimum of 10 seconds. the patient should be questioned about the provocation of symptoms and the patient's eyes should again be observed for nystagmus. head held still by the physiotherapist with active trunk rotation to left and right. In such cases. In patients whose physiological movements are restricted by pain or stiffness. provocative testing should be undertaken in supine lying or sitting as indicated by the patient’s history (subjective examination)25. head held still by the physiotherapist with sustained trunk rotation to left and right. cervical manipulation and any procedures involving end-range rotation should not be undertaken. including assessment for a latent response. including assessment for a latent response. Section 3 Assessment During and Following Treatment During and following administration of any cervical manipulative procedure or any cervical treatment procedure involving end-range rotation. testing should be undertaken on every occasion a cervical manipulation or any procedure involving end-range rotation is to be performed in an attempt to detect the patient for whom such treatments would be inappropriate as a result of provocation of symptoms or signs indicative of VBI. the risks associated with this procedure may be minimised by avoiding the following practices:22 • Non-specific multisegmental procedures. first aid practices implemented and emergency assistance sought. It is recommended that cervical mobilisation be used initially with its effects assessed over at least 24 hours prior to the application of cervical manipulation. The simulated manipulation position (pre-manipulative hold) is also recommended if manipulation is the proposed treatment1. or neck traction.3 Testing prior to manipulation or any treatment procedure involving end-range rotation If cervical manipulation or any cervical treatment procedure involving end-range rotation is being considered.3 above should be applied prior to continuation with treatment. • Procedures involving upper cervical spine rotation. APA Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders ©APA 2006 Page 5 of 14 . testing as outlined in Section 2. • During and immediately subsequent to any cervical treatment procedure involving end-range rotation. the physical (objective) examination guidelines outlined in Sections 2. The physiotherapist should exercise sound clinical reasoning in applying these guidelines to individual patients and be aware that responses to provocative testing performed at subsequent treatment sessions may change. Because a patient’s vascular status may change between treatment sessions. although other mobilisation procedures may be applied provided the patient is carefully monitored.2 and 2.2 is recommended. Specific questioning about symptoms and observation for signs associated with VBI is essential at the following points during management: • Immediately prior and subsequent to a cervical manipulative procedure. • At subsequent visits enquiry should be made as to whether any symptoms or signs associated with VBI.APA Clinical Guidelines 2. end-range cervical spine rotation or extension. If cervical manipulation is indicated. 30. Because provocative testing is limited in its predictive validity for adverse neurovascular events 26. If there is evidence of unclear symptoms or signs potentially associated with VBI from either the history (subjective examination) or physical (objective) examination. including assessment for a latent response. • Use of excessive thrusting force or range of movement. If an adverse neurovascular event occurs despite applying these guidelines then treatment should be immediately ceased. the physiotherapist must determine the presence or absence of symptoms and signs associated with VBI. If symptoms or signs associated with VBI are provoked during or following treatment. or neck pain or headache suggestive of vertebral artery dissection has been experienced. a report of symptoms potentially associated with VBI in the history (subjective examination) should be given greater weight in clinical decisionmaking than a negative test response. cervical manipulation and mobilisation should not be undertaken and referral to a medical practitioner initiated. Interpretation of findings It is recommended that: If there is evidence at any time that symptoms or signs are clearly associated with VBI. • During and immediately subsequent to any treatment of a patient who has reported symptoms associated with VBI in the history (subjective examination) or when such symptoms (or signs) are provoked during the physical examination. • Multiple manipulations of the same or different cervical joints in any one treatment session. in particular cervical manipulation or any cervical procedure involving end-range rotation. For any cervical treatment procedure that involves end-range rotation on each occasion such a procedure is performed.physiotherapy.2 Obtaining informed consent Informed consent is defined as 'the voluntary and revocable agreement of a competent individual to participate in a therapeutic or research procedure. The brochure is available from the APA website www.1) must be obtained: • • For cervical manipulation on each occasion a manipulative procedure is performed. It can be given to the patient to read in the waiting room or clinic prior to treatment or to take home if the patient needs further time to decide whether to proceed. appears to be less than that encountered in daily life. based on an adequate understanding of its nature. purpose. Obtaining Consent and Recording 4. Information provided about cervical manipulation should include the remote risks of stroke and death.1 above. Informed consent where a patient explicitly indicates agreement (either verbally or in writing) following adequate provision of information about the proposed procedure (see Section 4.1 Provision of information • • It is essential that physiotherapists provide patients with information about proposed treatment procedures.APA Clinical Guidelines Section 4 Consent: Provision of Information. or if there is further information that the patient would likely consider important. The physiotherapist has a responsibility to ensure that the patient understands the information provided. Given this legal opinion the APA recommends that the information provided to the patient of the risks inherent in the procedure should include specific mention of the risk of death. Consent is only valid if it is given freely and with an adequate understanding of what the procedure entails. Provision of an information sheet/brochure is optional but allows the patient the opportunity to read about the proposed procedure at their own pace and formulate any questions. Neck Mobilisation and Manipulation: The Facts Explained’ on the risks and benefits associated with cervical manipulation and mobilisation in which the above issues are essentially covered. as identified from review of the literature. Use of this brochure is recommended as an appropriate method of providing information to patients about cervical manipulation and mobilisation. whether delivered verbally or in writing. • • • • MPA has produced an information brochure entitled ‘Patient Information. Such information. even if the same procedure is repeated. 4. Information may be provided verbally by the physiotherapist. The physiotherapist must be prepared to verbally provide information beyond what is written in the information sheet/brochure if the patient requests further information. or preferably in an information sheet/brochure to ensure that the information is standardised. it is considered legally pertinent to mention the risk. even if the same procedure is repeated.au or in hardcopy from MPA. Whilst the risk of death from cervical manipulation. APA Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders ©APA 2006 Page 6 of 14 .asn. The physiotherapist may only ask for consent to proceed following the provision of information as outlined in Section 4. and implications'27. must cover the following: – information about the proposed procedure – alternatives to the proposed procedure – benefits and risks of the proposed procedure and alternatives – the opportunity to ask questions – the opportunity to have adequate time to reflect on the information provided before agreeing to the proposed procedure – the opportunity for the patient to change their mind during the procedure (where practical). APA Clinical Guidelines 4. It is also worth noting that some professional indemnity insurance policies require that signed consent be obtained prior to manipulation. I have understood the information provided. This is particularly important if the physiotherapist needs to seek consent for more than one procedure in the one treatment session. A stamp or sticker with the following information (available from the APA at www. • • APA Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders ©APA 2006 Page 7 of 14 . I consent to the proposed treatment.physiotherapy.3 Recording informed consent • Provision of information and obtaining of consent must be recorded in a standardised manner in the patient’s clinical notes at each treatment of cervical manipulation or any procedure involving end-range rotation. with care taken to record the date and time at which consent was given. It is essential that consent for each procedure is recorded separately. the APA recommends that the physiotherapist obtains signed consent prior to manipulation. Whilst it is not legally necessary to obtain written consent from the patient for any cervical procedure.asn.au) is recommended to facilitate such recording: RECORD OF INFORMED CONSENT Proposed treatment procedure: ___________________________ ____________________________________________________ Method(s) used to provide information: Verbal Written Discussion of treatment covered: What the treatment involves Potential benefits and risks of the proposed treatment Alternatives to the proposed treatment Opportunity for patient to ask questions Questions asked and answered Opportunity for patient to select alternative treatment Signed (Physiotherapist): ________________________________ Date: _______________________________ Time: ___________ I confirm that: I have been adequately informed about the proposed treatment. Signed (Patient): _______________________________________ Date: _______________________________ Time: ___________ • Each bullet point should be initialled by the physiotherapist. including manipulation. ...... CHECKLIST FOR CONTRA-INDICATIONS (AND PRECAUTIONS) TO MANIPULATION GENERAL 1.......................... and Boland.................................................................... ......................................................... in addition to ensuring that: a) APA Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders are followed prior to manipulation b) Consent is gained c) Vertebrobasilar insufficiency questionnaire is completed (cervical region only).......... ie: is pain constant? yes is pain related to movement? yes presence of severe spasm yes presence of morning stiffness (> half hour) yes presence of severe night pain yes presence of night sweats yes history of cancer yes recent trauma/fracture yes no no no no no no no no Comments:............................................M..............APA Clinical Guidelines Appendix 1 Checklist for Use Prior to Spinal Manipulation Reproduced from: Refshauge....D.................................................................... Manipulation is not usually considered an appropriate treatment for elderly patients..............A.................................. • • • • • Presence of symptoms of spinal cord compromise: non-dermatomal symptoms ataxia or clumsiness increased reflexes positive Babinski or clonus non-myotomal muscle weakness yes yes yes yes yes no no no no no Comments:................................ Larsen............................................................................................. ........... Shirley........................ teenagers or children................................D... DATE:...........D....... .............................................. Professional responsibility in relation to cervical spine manipulation..................................... Parry. • • • • • • • • Presence of signs/symptoms that indicate serious pathology.............................. Australian Journal of Physiotherapy 48: 171-179 (2002)....... Rivett... PATIENT’S NAME:........... R..........................................................................................................................................................................K................................................................................................................................................................. 2......................................................S............................................................ Screening consists of clearance by the treating physiotherapist by completing the following checklist.... APA Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders ©APA 2006 Page 8 of 14 .......... .... ............................................. 7.................................................................................................................. Signs and symptoms suggesting possible spinal instability (eg RA of upper cervical spine): yes no Comments:..........................................................................................................APA Clinical Guidelines 3........................... ..................................................................................................................................................................................................................................................................... Other contra-indications and precautions to manipulation: • non-mechanical pain yes • presence of psychiatric or depressive illness yes • other (eg spondylolisthesis......................................................................................................................................................... Symptoms of acute spinal nerve/nerve root compromise: • dermatomal pain...................................................... ................................................................................................................................................................................................................................................................................................................................ APA Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders ©APA 2006 Page 9 of 14 ................................................................. 4............................................................................................................................................................................................... Presence of a relevant recent soft tissue injury (eg whiplash): yes no Comments:. ...... ...................................... .............................................................................................................................. ...................... known disc disease) yes no no no Comments:........................................................................................................................................................................................... 6.................................................................................................................... ...................... .. .................... .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. • • • • • • Presence of symptoms or signs of the following conditions: active infection yes active Scheuermann’s disease yes osteoporosis/osteopaenia yes pregnancy yes advanced diabetes yes inflammatory disease yes no no no no no no Comments:..................... 8................................................................................................................................... ................................................................................................... paraesthesia or anaesthesia yes • decreased reflexes yes • decreased muscle power (myotomal) yes • production of neurological signs or symptoms on spinal movement yes no no no no Comments:.......... 5........................................................................................................................................................................... .............................................................................................. • • • • • • Use of medication: anti-depressants oral steroids anti-coagulant therapy strong analgesics muscle relaxants opiates yes yes yes yes yes yes no no no no no no Comments:.................... .................................................................................. ARE FURTHER INVESTIGATIONS NECESSARY? Please give further information about what investigations are required and why: ............................................................................... • • • • • • • • • • • • • Presence of signs or symptoms of vertebrobasilar insufficiency (VBI): previous diagnosis of VBI yes no visual disturbances yes no dizziness or vertigo yes no blurred vision yes no diplopia yes no nausea yes no tinnitus yes no drop attacks yes no dysarthria yes no dysphagia yes no facial or intra-oral anaesthesia or paraesthesia yes no above symptoms aggravated by neck position or movement yes no previous possible VBI episode provoked by cervical manipulation yes no Comments:..................................................... Presence of cauda equina syndrome: • saddle anaesthesia or paraesthesia • sphincter dysfunction yes yes no no Comments:.................... SPECIFIC TO LUMBAR SPINE MANIPULATION 10...................................................................................................................................................... APA Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders ©APA 2006 Page 10 of 14 ........................................................ DATE: ............................................................................................................ ............ ............................................................................................................................................................................................... .............APA Clinical Guidelines SPECIFIC TO CERVICAL SPINE MANIPULATION 9.............................................……............................................................................................................................................................................................................... ................................................................. .......................................................................................................................................................................…...................................................................................... .............................................................................................................................................................................................................. SIGNATURE OF EXAMINER: ................................................................................................ to provide clinicians with an ‘at-aglance’ reminder of the assessment procedure and the recommended practice following a given outcome at any stage of the process.APA Clinical Guidelines Appendix 2 Clinical Flowchart A full-colour clinical flowchart is available with these clinical guidelines. The clinical flowchart is available in hardcopy or PDF format. Please contact the Australian Physiotherapy Assocation to obtain a copy. APA Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders ©APA 2006 Page 11 of 14 . pp. & Stoneham. (2000). P.. P. San Diego: Singular Publishing Group Inc. R. Manipulation of the cervical spine: Risks and benefits.).. APA Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders ©APA 2006 Page 12 of 14 .. revision and new clinical guidelines. 249. P. 11. 24. 159-164. R.APA Clinical Guidelines Appendix 3 References 1.. M. H. Y. B. Grimmer.. N. Blood flow velocities in basilar artery during rotation of the head. (2001).. 14. Bourassa. S. Zhang. Rivett.. J. 179-182. Arnold. Kreitz. Kohlbeck. 15.175-177.. In L.-Z. (2001). Coban. Color duplex sonographic findings in human vertebral arteries during cervical rotation. The validity of the extension-rotation test as a clinical screening procedure before neck manipulation: A secondary analysis. & Refshauge. 29. Li. Hedera.. P. M. 33-36). . 785794. H. New York: Oxford University Press. (2002). 229-233. 13.. F. B. Davies.. Stroke. (1993)... 16. Doppler studies evaluating the effect of a physical therapy screening protocol on vertebral artery blood flow. Gurol. Spine. E. Mann. W. (1999). Christensen. & Zhong. E.). & McGregor. Changes and implications of blood flow velocity of the vertebral artery during rotation and extension of the head. Journal of Manipulative and Physiological Therapeutics.. Kohlbeck.-M. W. & Halmaggi. 10. Y. Licht. (2004). Haldeman. Handbook of Vestibular Rehabilitation (pp. T. F. G. & Triano.. & Bahar. P. Haldeman. O. 7. Licht. G. J. Journal of Manipulative and Physiological Therapeutics. Manual Therapy. Causes of complications from cervical spine manipulation. K. Lu. Acta Neurologica Scandinavica. Combs. 23. Haynes. J.D. 274-278. & McGregor. F. (1996). 88. Journal of Clinical Ultrasound. W. Review. J.. Tuncay. 6. & Refshauge. S.. 21. Is there a role for premanipulative testing before cervical manipulation? Journal of Manipulative and Physiological Therapeutics. Licht. J. and cervical spine manipulation therapy. Langer. Krespi. Premanipulative testing of the cervical spine. 13-21. 12.. 9. P. Journal of Neurology. 363-367.. 22. (1997)... 9. (1999). 8. Bujdáková. C.. & Høilund-Carlsen. (1999). S. (1998). P. 1098-1104.. 5065. 175179.-K. Vertebral artery dissection presenting with isolated neck pain. Højgaard. P. Disorders of the Vestibular System. Di Fabio. H. R. Manual Therapy. B.. 2. Journal of Manipulative and Physiological Therapeutics. Coughlan.. 95-108. T. Vertebral artery volume flow in human beings. B. 17. M. & Høilund-Carlsen. S.. K. J. 27-31. M. H. (Eds. cerebral artery dissection. (2002). & Milne.. Davies (Eds. F. & Høilund-Carlsen. Christensen. 79. F.. (2004). Journal of Manipulative and Physiological Therapeutics. W. P. Christensen. A. P. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. D.. & Traubner. Luxon & R. M. 3. R. P. Rebbeck.. Disorders of balance.. 22.-K. Journal of Manipulative and Physiological Therapeutics. 5. M. 47. C. 9. A. S. Australian Journal of Physiotherapy. Triplex ultrasound of vertebral artery flow during cervical rotation. (1997). Baloh. A. M. 91-95. G. B. Magarey.. (1996). B.. & Thiel. (1999).. Symptoms of neck artery compromise: Case presentations of risk estimate for treatment. 20.. Cassidy. 14-24. T. Physical Therapy. J. Journal of Neuroimaging. K. R. Côté. 19. 12. 4. Y. 255-266.. 24.. J. (2003). Larsen. Sharples. G. M. L.). Perth: International Federation of Orthopaedic and Manipulative Therapists. Munshi. 78-84. Grieve’s Modern Manual Therapy of the Vertebral Column (3rd ed. Vertebral artery blood flow during pre-manipulative testing of the cervical spine. 8. Van der Velde. S. Boyling & G. 30. K. 105-110. 15-19. J. Rivett. D. 22. Journal of Manipulative and Physiological Therapeutics. (2005).. 48. Thiel.. C. 368-375. 27. D. 104-106. J. 23. Is it time to stop functional pre-manipulative testing of the cervical spine? Manual Therapy. 17. Mitchell. Dyson. Pruvey. P. 31. 81. Professional responsibility in relation to cervical spine manipulation. D. Edinburgh: Churchill Livingstone. (1999). & Phillips. C. Thomas. & Milburn. Journal of the Canadian Chiropractic Association. & Bolton. pp. Effect of pre-manipulative tests on vertebral artery and internal carotid artery blood flow: A pilot study. 28.. Rivett. Donat. Journal of Manipulative and Physiological Therapeutics. A. 32. 347-351.. 2.. M. K. Jull (Eds. Manual Therapy.. associated with a measurable change in intracranial vertebral artery blood flow? Manual Therapy. A. A. 220-227. as used in the standard vertebrobasilar insufficiency test. L. M. Boyling & G. D. D. Parry. D. R.. Dawson. (2004). & Robinson.APA Clinical Guidelines 18. P. (1996). Refshauge. Functional Doppler sonography of the vertebral artery and some considerations about manual techniques. S. D. Proceedings of the International Federation of Orthopaedic and Manipulative Therapists Conference (pp. A.. pp. In J. 103-109.. Changes in vertebral artery blood flow following normal rotation of the cervical spine. 9... 43. Dansie... & Spyropolous. 533-549). Jull (Eds. 387-390). J.. Sharples. (2003). B. Harvey. W. Is cervical spine rotation. 33.. K. A. (2004). Adverse effects of cervical manipulative therapy. 257-273). R.. A. 31-40. Shirley. Pre-manipulative testing: Where do we go from here? New Zealand Journal of Physiotherapy.. 9.. Rivett. K. J. (1991). & Boland. 154-158.. APA Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders ©APA 2006 Page 13 of 14 . 25.. (1994). 26. In J. A. Stevens. Sim. R. 33. Carotid and vertebral artery dissection syndromes. 171-179. D. Rivett. Zaina. (2002). Clinical Biomechanics. Journal of Manual Medicine. G. 10. Manual Therapy. Australian Journal of Physiotherapy. 383-388. Effect of various head and neck positions on vertebral artery blood flow.. P. The vertebral artery and vertebrobasilar insufficiency. (1999).. Johnson. The effect of cervical rotation on blood flow in the contralateral vertebral artery. A. D. & Yong-Hing. G. 26. & Milburn. Edinburgh: Churchill Livingstone. Thiel.. (1994). 6. (2000). 20. K. Grant. Mitchell.). 29.. 21. D.. Benign paroxysmal positional vertigo.. C. 22. 102-105. H. Postgraduate Medical Journal. P. (2005).. 19. (2004). J. Thanvi. Rivett. Informed consent and manual therapy. S. Rivett.. H. (2004). T. Refshauge. Keene. Rotation: A valid premanipulative dizziness test? Does it predict safe manipulation? Journal of Manipulative and Physiological Therapeutics.. K. K. & Rix. C. L. D. Part 1: Background and clinical presentation. D. Wallace. Taylor. B. Grieve’s Modern Manual Therapy of the Vertebral Column (3rd ed. The University of Newcastle Chair. University of South Australia Author Professor.APA Clinical Guidelines Appendix 4 Acknowledgements The APA and MPA wish to acknowledge the following individuals for contributing their time and expertise in the development of this revised document: Dr Darren Rivett Author Associate Professor. MPA Academic and Professional Standards Committee Author and Project Manager Lecturer. APA Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders ©APA 2006 Page 14 of 14 . The University of Sydney Former MPA National Chair Author Senior Lecturer. The University of Sydney Consultant Lawyers and Consultants MPA National Chair MPA National Manager Dr Debra Shirley Dr Mary Magarey Dr Kathryn Refshauge Dr Elizabeth Ellis McKean and Park Michael Ryan Kirsty Greenwood MPA members who participated in the focus groups and survey The individuals and organisations who contributed to the original APA Clinical Guidelines for Premanipulative Procedures for the Cervical Spine (2000) are also acknowledged.