Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the ...

Clinical Guidelinesfor Assessing Vertebrobasilar Insufficiencyin the Management of Cervical Spine DisordersRevised February 2006Authors:Associate Professor Darren RivettDr Debra ShirleyDr Mary MagareyProfessor Kathryn RefshaugeThese guidelines comprise a set of recommendations regarding assessing for vertebrobasilar insufficiencyand 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 Pre-Manipulative Procedures for the Cervical Spine (2000).The APA wishes to acknowledge Musculoskeletal Physiotherapy Australia (MPA), for the revision of theseguidelines.© Copyright Australian Physiotherapy Association 2006This work is copyright. Apart from any use permitted under the Copyright Act 1968, no part may bereproduced by any process without prior written permission from the APA.Australian Physiotherapy AssociationPO Box 6465, St Kilda Road CentralVictoria 8008 AustraliaPhone +61 3 9534 9400Fax +61 3 9534 9199Email: national.office@physiotherapy.asn.auWebsite: www.physiotherapy.asn.auMPA IS A NATIONAL SPECIAL GROUP OF THE APA

APA Clinical GuidelinesIntroductionCLINICAL GUIDELINESFOR ASSESSING VERTEBROBASILAR INSUFFICIENCYIN THE MANAGEMENT OF CERVICAL SPINE DISORDERSFebruary 2006The presence or development of dizziness, or other possible symptoms of vertebrobasilar insufficiency(VBI) should be carefully assessed in any patient for whom examination or treatment of the cervical spine isto be undertaken. It is important that the physiotherapist has the knowledge needed to recognise symptomsand signs potentially associated with VBI. To ensure safe practice, the physiotherapist must also have athorough understanding of the implications of such symptoms and signs in the management of cervicalspine disorders. The aim of these clinical guidelines is to facilitate the clinical recognition of VBI by allphysiotherapists who treat the cervical spine using procedures which could compromise the vertebral arteryor trigger adverse neurovascular events, most notably cervical manipulation and mobilisation 16, 17 . For thepurpose of these clinical guidelines, manipulation is defined as a procedure involving a high velocity thrust,whereas the term mobilisation refers to any other manual joint movement procedure applied to the cervicalspine.This document details the symptoms and signs that may be potentially associated with VBI, together withclinical guidelines recommended by the Australian Physiotherapy Association (APA) and MusculoskeletalPhysiotherapy Australia (MPA, a National Special Group of the APA) for examination and treatment of allpatients with disorders of the cervical spine. While the clinical guidelines are recommended, they areprimarily provided to help inform the clinical reasoning of the physiotherapist in their management of theindividual patient. The document also describes the recommended procedure for provision of information topatients about cervical manipulation and mobilisation, obtaining consent and the recording of these steps.The physiotherapist is reminded that VBI is not the only safety consideration when assessing and treatingthe cervical spine, and to this end a checklist for use prior to spinal manipulation 21 is included for informationin Appendix 1. A summative Clinical Flowchart for the appropriate application of cervical manipulation andmobilisation procedures involving end-range rotation is included in Appendix 2. Key supporting referencesare found in Appendix 3.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. However, if appropriatelyselected and performed with care (including only to the initial point of provocation of symptoms), anypotential risk to the patient will be minimised. The provocation of symptoms or signs during testingshould alert the physiotherapist to the need for particular care in the selection of examination andtreatment procedures.• The recommended tests are the most valid procedures for determining the presence of VBI and theadequacy of the collateral circulation identified in the literature to date 3, 6 . Although the tests have shownmixed results in relation to changes in vertebrobasilar arterial blood flow in experimental studies24, 33 1, 4, 9, 12, 13, 14, 15, 18, 19, 20, 24, 25,, it appears that end-range rotation is the most sensitive cervical position28, 31 . Recent research has also identified blood flow changes in the simulated manipulation position 1 .• There is no simple clinical method for testing the intrinsic state of the vertebral artery andphysiotherapists should be cognisant of this when examining or treating the cervical spine. Therecommended tests will not identify all patients at risk of suffering an adverse event following cervicalmanipulation or mobilisation.Assessment for the presence of symptoms and signs associated with VBI occurs at four stages in themanagement of a patient with an upper quadrant disorder:1. History (subjective examination)2. Physical (objective) examination3. During treatment of the cervical spine, and4. Following treatment.10, 15, 20, 23,Decisions on management, including choice of treatment, should be continually (re-)evaluated on the basisof the outcome of these assessments.APA Clinical Guidelines ©APA 2006 Page 2 of 14for Assessing Vertebrobasilar Insufficiencyin the Management of Cervical Spine Disorders

APA Clinical GuidelinesSection 1. History (Subjective Examination)In every patient presenting with upper quadrant dysfunction, questioning is specifically directed todetermine the presence of dizziness which is the most common presenting symptom of VBI. If dizziness ispresent, other symptoms associated with VBI should be sought, including:• Visual disturbances such as diplopia (double vision), 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, tremors and sweating• Other neurological symptoms.Enquiry should also determine the nature of any neck pain or headache, which are usually the firstsymptoms of dissection of the vertebral artery. Specifically, sudden, severe, sharp pain located in theipsilateral postero-superior region of the neck and occiput and for which there is no past history should beregarded as suspicious 8, 11 . Patients may also report a history of cervical trauma 7 or neck stiffness, and theirneck range of motion can be restricted. Pain usually precedes ischaemic symptoms and signs, with the timeinterval varying among individuals 29 . Until the ischaemic response becomes manifest it can be difficult todifferentiate a dissecting vertebral artery from a benign mechanical neck disorder. It is therefore prudent toinitially treat conservatively and carefully monitor progress.Should the patient suffer from any of the symptoms associated with VBI described above, then questioningshould explore the symptoms further, including:• The type, degree, frequency and duration of the dizziness or other symptoms• The production or aggravation of the symptoms by neck movements or sustained positions, particularlythose 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.Some features may facilitate differentiation of dizziness or other symptoms associated with VBI from similar2, 5, 32symptoms produced by other conditions:• 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, if from alow to a high position, orthostatic hypotension– by rolling in bed rather than by head movement is typical of a vestibular disorder, particularly ifaccompanied by nystagmus• Symptoms and nystagmus that are latent, fatiguable and habituate are typical of a vestibular disorder.When nystagmus is associated with VBI, it demonstrates no fatiguability.It should be noted, however, that other conditions such as vestibular disease, ear disease, cardiovasculardisease, migraine, epilepsy, stroke and head injury may co-exist with VBI 2, 5, 32 .APA Clinical Guidelines ©APA 2006 Page 3 of 14for Assessing Vertebrobasilar Insufficiencyin the Management of Cervical Spine Disorders

APA Clinical GuidelinesSection 2. Physical (Objective) Examination2.1 Routine examination for all patients with upper quadrant dysfunctionIn every patient for whom treatment of the cervical spine is to be performed, routine physical examination ofthe cervical spine must be undertaken, including physiological movements to the end of available range withoverpressure (where applicable). Physiotherapists should enquire about the presence of any symptomsassociated with VBI and observe for any signs regularly throughout the physical (objective) examination,most notably during cervical physiological and accessory movement testing. In patients whose physiologicalmovements are restricted by pain or stiffness, the vertebrobasilar system may not be adequatelycompromised. Physiotherapists should be mindful of this limitation to their examination and consider thisinformation in their decision-making about treatment choice.2.2 Testing for patients who report symptoms associated with VBI during thehistory (subjective examination)If reported symptoms are clearly indicative of VBI or vertebral artery dissection then provocative testing is notrequired and medical opinion should be sought prior to undertaking any examination or treatment of thecervical spine. In such cases, the physiotherapist should be mindful that the tests by their very nature can bestressful to the vertebral artery. When symptoms are undifferentiated or unclear as to their origin, provocativetesting should be undertaken in supine lying or sitting as indicated by the patient’s history (subjectiveexamination) 25, 33 .If dizziness or other symptoms are provoked in either of these positions (i.e. supine lying or sitting), the testcan be repeated in the alternative position. This will facilitate differentiation between symptoms caused byVBI and those related to the vestibular system. This is because the vestibular system is affected by gravityso that symptoms will be different in supine lying compared to sitting, whereas symptoms related to VBI willbe essentially unchanged 32 .The recommended minimum testing for a patient who reports symptoms associated with VBI (but which arenot 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 consideredwhich is equal or greater in vigour to this test 25 .‣ All positions should be sustained for a minimum of 10 seconds, unless symptoms or signs are provokedsooner. The physiotherapist should examine the patient’s eyes for the production of nystagmus whilethe neck is held in the sustained position and simultaneously question the patient about the(re)production of symptoms.‣ On return to neutral from the sustained position, a period of at least 10 seconds should be allowedbefore proceeding with the next examination procedure. During this time, the patient should bequestioned about the provocation of symptoms and the patient's eyes should again be observed fornystagmus. Physiotherapists should be aware of the potential for a latent response to movement andpositional testing.‣ Provocative testing should be immediately ceased upon provocation of symptoms or signs clearlyindicative of VBI.The physiotherapist must determine the benefit of additional testing for any particular patient based on theirclinical presentation. If additional testing is required to further test for the presence of symptoms or signsassociated with VBI or further test collateral circulation, upper cervical extension can be added to end-rangerotation and sustained as described above.If dizziness is provoked upon rotation movement or sustained position and its origin is unclear, rotation canbe further explored in the standing position in order to differentiate dizziness arising from the vestibularapparatus of the inner ear from that arising from the cervical spine (either cervical vertigo or VBI):• For positional provocation, head held still by the physiotherapist with sustained trunk rotation to left andright.• For movement provocation, head held still by the physiotherapist with active trunk rotation to left andright.Again, sustained positions are held for a minimum of 10 seconds, or less if symptoms or signs are provoked.Provocation of dizziness during differentiation testing suggests that it is not caused by a vestibular disorder.APA Clinical Guidelines ©APA 2006 Page 4 of 14for Assessing Vertebrobasilar Insufficiencyin the Management of Cervical Spine Disorders

APA Clinical Guidelines2.3 Testing prior to manipulation or any treatment procedure involving end-rangerotationIf cervical manipulation or any cervical treatment procedure involving end-range rotation is being considered,testing as outlined in Section 2.2 is recommended. The simulated manipulation position (pre-manipulativehold) is also recommended if manipulation is the proposed treatment 1 . Because a patient’s vascular statusmay change between treatment sessions, testing should be undertaken on every occasion a cervicalmanipulation or any procedure involving end-range rotation is to be performed in an attempt to detect thepatient for whom such treatments would be inappropriate as a result of provocation of symptoms or signsindicative of VBI.Interpretation of findingsIt is recommended that:‣ If there is evidence at any time that symptoms or signs are clearly associated with VBI, cervicalmanipulation and mobilisation should not be undertaken and referral to a medical practitioner initiated.‣ If there is evidence of unclear symptoms or signs potentially associated with VBI from either the history(subjective examination) or physical (objective) examination, cervical manipulation and any proceduresinvolving end-range rotation should not be undertaken, although other mobilisation procedures maybe applied provided the patient is carefully monitored. Because provocative testing is limited in itspredictive validity for adverse neurovascular events 26, 30 , a report of symptoms potentially associatedwith VBI in the history (subjective examination) should be given greater weight in clinical decisionmakingthan a negative test response.‣ The physiotherapist should exercise sound clinical reasoning in applying these guidelines to individualpatients and be aware that responses to provocative testing performed at subsequent treatmentsessions may change.‣ If an adverse neurovascular event occurs despite applying these guidelines then treatment should beimmediately ceased, first aid practices implemented and emergency assistance sought.Section 3Assessment During and Following TreatmentDuring and following administration of any cervical manipulative procedure or any cervical treatmentprocedure involving end-range rotation, the physiotherapist must determine the presence or absence ofsymptoms and signs associated with VBI. Specific questioning about symptoms and observation for signsassociated with VBI is essential at the following points during management:• Immediately prior and subsequent to a cervical manipulative procedure, including assessment for alatent response.• During and immediately subsequent to any cervical treatment procedure involving end-range rotation,including assessment for a latent response.• During and immediately subsequent to any treatment of a patient who has reported symptomsassociated with VBI in the history (subjective examination) or when such symptoms (or signs) areprovoked during the physical examination, including assessment for a latent response.• At subsequent visits enquiry should be made as to whether any symptoms or signs associated with VBI,or neck pain or headache suggestive of vertebral artery dissection has been experienced.If symptoms or signs associated with VBI are provoked during or following treatment, the physical (objective)examination guidelines outlined in Sections 2.2 and 2.3 above should be applied prior to continuation withtreatment.If cervical manipulation is indicated, the risks associated with this procedure may be minimised by avoidingthe following practices: 22• Non-specific multisegmental procedures.• Procedures involving upper cervical spine rotation, end-range cervical spine rotation or extension, orneck traction.• Use of excessive thrusting force or range of movement.• Multiple manipulations of the same or different cervical joints in any one treatment session.It is recommended that cervical mobilisation be used initially with its effects assessed over at least 24 hoursprior to the application of cervical manipulation.APA Clinical Guidelines ©APA 2006 Page 5 of 14for Assessing Vertebrobasilar Insufficiencyin the Management of Cervical Spine Disorders

APA Clinical GuidelinesSection 4Consent: Provision of Information, Obtaining Consent and Recording4.1 Provision of information• It is essential that physiotherapists provide patients with information about proposed treatmentprocedures, in particular cervical manipulation or any cervical procedure involving end-range rotation.• Information may be provided verbally by the physiotherapist, or preferably in an informationsheet/brochure to ensure that the information is standardised. Such information, whether deliveredverbally or in writing, 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 theproposed procedure– the opportunity for the patient to change their mind during the procedure (where practical).• Provision of an information sheet/brochure is optional but allows the patient the opportunity to read aboutthe proposed procedure at their own pace and formulate any questions. It can be given to the patient toread in the waiting room or clinic prior to treatment or to take home if the patient needs further time todecide whether to proceed.• The physiotherapist must be prepared to verbally provide information beyond what is written in theinformation sheet/brochure if the patient requests further information, or if there is further information thatthe patient would likely consider important.• Information provided about cervical manipulation should include the remote risks of stroke and death.Whilst the risk of death from cervical manipulation, as identified from review of the literature, appears tobe less than that encountered in daily life, it is considered legally pertinent to mention the risk. Giventhis legal opinion the APA recommends that the information provided to the patient of the risksinherent in the procedure should include specific mention of the risk of death.• The physiotherapist has a responsibility to ensure that the patient understands the information provided.MPA has produced an information brochure entitled ‘Patient Information, Neck Mobilisation andManipulation: The Facts Explained’ on the risks and benefits associated with cervical manipulation andmobilisation in which the above issues are essentially covered. Use of this brochure is recommended as anappropriate method of providing information to patients about cervical manipulation and mobilisation. Thebrochure is available from the APA website www.physiotherapy.asn.au or in hardcopy from MPA.4.2 Obtaining informed consentInformed consent is defined as 'the voluntary and revocable agreement of a competent individual toparticipate in a therapeutic or research procedure, based on an adequate understanding of its nature,purpose, and implications' 27 . Informed consent where a patient explicitly indicates agreement (either verballyor in writing) following adequate provision of information about the proposed procedure (see Section 4.1)must be obtained:• For cervical manipulation on each occasion a manipulative procedure is performed, even if the sameprocedure is repeated.• For any cervical treatment procedure that involves end-range rotation on each occasion such aprocedure is performed, even if the same procedure is repeated.The physiotherapist may only ask for consent to proceed following the provision of information as outlined inSection 4.1 above. Consent is only valid if it is given freely and with an adequate understanding of what theprocedure entails.APA Clinical Guidelines ©APA 2006 Page 6 of 14for Assessing Vertebrobasilar Insufficiencyin the Management of Cervical Spine Disorders

APA Clinical Guidelines4.3 Recording informed consent• Provision of information and obtaining of consent must be recorded in a standardised manner in thepatient’s clinical notes at each treatment of cervical manipulation or any procedure involving end-rangerotation. A stamp or sticker with the following information (available from the APA atwww.physiotherapy.asn.au) is recommended to facilitate such recording:RECORD OF INFORMED CONSENTProposed treatment procedure: _______________________________________________________________________________Method(s) used to provide information: Verbal WrittenDiscussion 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 treatmentSigned (Physiotherapist): ________________________________Date: _______________________________ Time: ___________I confirm that:•I have been adequately informed about the proposed treatment.•I have understood the information provided.•I consent to the proposed treatment.Signed (Patient): _______________________________________Date: _______________________________ Time: ___________• Each bullet point should be initialled by the physiotherapist, with care taken to record the date and timeat which consent was given. This is particularly important if the physiotherapist needs to seek consentfor more than one procedure in the one treatment session. It is essential that consent for eachprocedure is recorded separately.• Whilst it is not legally necessary to obtain written consent from the patient for any cervicalprocedure, including manipulation, the APA recommends that the physiotherapist obtainssigned consent prior to manipulation.• It is also worth noting that some professional indemnity insurance policies require that signed consentbe obtained prior to manipulation.Disclaimer:These clinical guidelines have been prepared having regard to general circumstances, and it is theresponsibility of the practitioner to have express regard to the particular circumstances of each case, andthe application of these guidelines in each case. In particular, clinical management must always beresponsive to the needs of individual patients, resources and limitations unique to the institutions or type ofpractice. These clinical guidelines have been prepared having regard to the information available at thetime of their preparation, and the practitioner should therefore have regard to any information, research ormaterial which may have been published or become available subsequently. While the APA endeavours toensure that clinical guidelines are as current as possible at the time of their preparation, it takes noresponsibility for matters arising from changed circumstances or information or material which may havebecome available subsequently.APA Clinical Guidelines ©APA 2006 Page 7 of 14for Assessing Vertebrobasilar Insufficiencyin the Management of Cervical Spine Disorders

APA Clinical GuidelinesAppendix 1Checklist for Use Prior to Spinal ManipulationReproduced from: Refshauge,K.M., Parry,S., Shirley,D., Larsen,D., Rivett,D.A. and Boland, R. Professionalresponsibility in relation to cervical spine manipulation. Australian Journal of Physiotherapy 48: 171-179(2002).PATIENT’S NAME:.....................................................DATE:.........................................................................Manipulation is not usually considered an appropriate treatment for elderly patients, teenagers or children.Screening consists of clearance by the treating physiotherapist by completing the following checklist, inaddition to ensuring that:a) APA Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical SpineDisorders are followed prior to manipulationb) Consent is gainedc) Vertebrobasilar insufficiency questionnaire is completed (cervical region only).GENERALCHECKLIST FOR CONTRA-INDICATIONS (AND PRECAUTIONS) TO MANIPULATION1. Presence of signs/symptoms that indicate serious pathology, ie:• is pain constant? yes no • is pain related to movement? yes no • presence of severe spasm yes no • presence of morning stiffness (> half hour) yes no • presence of severe night pain yes no • presence of night sweats yes no • history of cancer yes no • recent trauma/fracture yes no Comments:.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................2. Presence of symptoms of spinal cord compromise:• non-dermatomal symptoms yes no • ataxia or clumsiness yes no • increased reflexes yes no • positive Babinski or clonus yes no • non-myotomal muscle weakness yes no Comments:.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................APA Clinical Guidelines ©APA 2006 Page 8 of 14for Assessing Vertebrobasilar Insufficiencyin the Management of Cervical Spine Disorders

APA Clinical Guidelines3. Presence of symptoms or signs of the following conditions:• active infection yes no • active Scheuermann’s disease yes no • osteoporosis/osteopaenia yes no • pregnancy yes no • advanced diabetes yes no • inflammatory disease yes no Comments:.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................4. Signs and symptoms suggesting possible spinal instability(eg RA of upper cervical spine): yes no Comments:.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................5. Symptoms of acute spinal nerve/nerve root compromise:• dermatomal pain, paraesthesiaor anaesthesia yes no • decreased reflexes yes no • decreased muscle power (myotomal) yes no • production of neurological signsor symptoms on spinal movement yes no Comments:.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................6. Presence of a relevant recent soft tissue injury(eg whiplash): yes no Comments:......................................................................................................................................................................................................................................................................................................................................................................................................7. Use of medication:• anti-depressants yes no • oral steroids yes no • anti-coagulant therapy yes no • strong analgesics yes no • muscle relaxants yes no • opiates yes no Comments:.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................8. Other contra-indications and precautions to manipulation:• non-mechanical pain yes no • presence of psychiatric or depressive illness yes no • other (eg spondylolisthesis, known disc disease) yes no Comments:.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................APA Clinical Guidelines ©APA 2006 Page 9 of 14for Assessing Vertebrobasilar Insufficiencyin the Management of Cervical Spine Disorders

APA Clinical GuidelinesSPECIFIC TO CERVICAL SPINE MANIPULATION9. 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 byneck position or movement yes no • previous possible VBI episode provokedby cervical manipulation yes no Comments:.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................SPECIFIC TO LUMBAR SPINE MANIPULATION10. Presence of cauda equina syndrome:• saddle anaesthesia or paraesthesia yes no • sphincter dysfunction yes no Comments:.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ARE FURTHER INVESTIGATIONS NECESSARY?Please give further information about what investigations are required and why:.......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................SIGNATURE OF EXAMINER: ..................................................……......DATE: ..........…..............................................APA Clinical Guidelines ©APA 2006 Page 10 of 14for Assessing Vertebrobasilar Insufficiencyin the Management of Cervical Spine Disorders

APA Clinical GuidelinesAppendix 2Clinical FlowchartA full-colour clinical flowchart is available with these clinical guidelines, to provide clinicians with an ‘at-aglance’reminder of the assessment procedure and the recommended practice following a given outcome atany stage of the process.The clinical flowchart is available in hardcopy or PDF format. Please contact the Australian PhysiotherapyAssocation to obtain a copy.APA Clinical Guidelines ©APA 2006 Page 11 of 14for Assessing Vertebrobasilar Insufficiencyin the Management of Cervical Spine Disorders

APA Clinical GuidelinesAppendix 3References1. Arnold, C., Bourassa, R., Langer, T., & Stoneham, G. (2004). Doppler studies evaluating the effect of aphysical therapy screening protocol on vertebral artery blood flow. Manual Therapy, 9, 13-21.2. Baloh, R. W., & Halmaggi, G. M. (Eds.). (1996). Disorders of the Vestibular System. New York: OxfordUniversity Press, pp.175-177.3. Combs, S. B., & Triano, J. J. (1997). Symptoms of neck artery compromise: Case presentations of riskestimate for treatment. Journal of Manipulative and Physiological Therapeutics, 20, 274-278.4. Côté, P., Kreitz, B. G., Cassidy, J. .D., & Thiel, H. (1996). The validity of the extension-rotation test as aclinical screening procedure before neck manipulation: A secondary analysis. Journal of Manipulativeand Physiological Therapeutics, 19, 159-164.5. Davies, R. A.. (1997). Disorders of balance. In L. M. Luxon & R. A. Davies (Eds.), Handbook ofVestibular Rehabilitation (pp. 33-36). San Diego: Singular Publishing Group Inc.6. Di Fabio, R. P. (1999). Manipulation of the cervical spine: Risks and benefits. Physical Therapy, 79, 50-65.7. Haldeman, S., Kohlbeck, F. J., & McGregor, M. (1999). Risk factors and precipitating neck movementscausing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine, 24, 785-794.8. Haldeman, S., Kohlbeck, F. J., & McGregor, M. (2002). Stroke, cerebral artery dissection, and cervicalspine manipulation therapy. Journal of Neurology, 249, 1098-1104.9. Haynes, M. J., & Milne, N. (2001). Color duplex sonographic findings in human vertebral arteries duringcervical rotation. Journal of Clinical Ultrasound, 29, 14-24.10. Hedera, P., Bujdáková, J., & Traubner, P. (1993). Blood flow velocities in basilar artery during rotation ofthe head. Acta Neurologica Scandinavica, 88, 229-233.11. Krespi, Y., Gurol, M. E., Coban, O., Tuncay, R., & Bahar, S. (2002). Vertebral artery dissectionpresenting with isolated neck pain. Journal of Neuroimaging, 12, 179-182.12. Li, Y.-K., Zhang, Y.-K., Lu, C.-M., & Zhong, S.-Z. (1999). Changes and implications of blood flow velocityof the vertebral artery during rotation and extension of the head. Journal of Manipulative andPhysiological Therapeutics, 22, 91-95.13. Licht, P. B., Christensen, H. W., & Høilund-Carlsen, P. F. (1999). Vertebral artery volume flow in humanbeings. Journal of Manipulative and Physiological Therapeutics, 22, 363-367.14. Licht, P. B., Christensen, H. W., & Høilund-Carlsen, P. F. (2000). Is there a role for premanipulativetesting before cervical manipulation? Journal of Manipulative and Physiological Therapeutics, 23, 175-179.15. Licht, P. B., Christensen, H. W., Højgaard, P., & Høilund-Carlsen, P. F. (1998). Triplex ultrasound ofvertebral artery flow during cervical rotation. Journal of Manipulative and Physiological Therapeutics, 21,27-31.16. Magarey, M. E., Rebbeck, T., Coughlan, B., Grimmer, K., Rivett, D. A., & Refshauge, K. (2004). Premanipulativetesting of the cervical spine. Review, revision and new clinical guidelines. Manual Therapy,9, 95-108.17. Mann, T., & Refshauge, K. (2001). Causes of complications from cervical spine manipulation. AustralianJournal of Physiotherapy, 47, 255-266.APA Clinical Guidelines ©APA 2006 Page 12 of 14for Assessing Vertebrobasilar Insufficiencyin the Management of Cervical Spine Disorders

APA Clinical Guidelines18. Mitchell, J. (2003). Changes in vertebral artery blood flow following normal rotation of the cervical spine.Journal of Manipulative and Physiological Therapeutics, 26, 347-351.19. Mitchell, J., Keene, D., Dyson, C., Harvey, L., Pruvey, C., & Phillips, R. (2004). Is cervical spine rotation,as used in the standard vertebrobasilar insufficiency test, associated with a measurable change inintracranial vertebral artery blood flow? Manual Therapy, 9, 220-227.20. Refshauge, K. M. (1994). Rotation: A valid premanipulative dizziness test? Does it predict safemanipulation? Journal of Manipulative and Physiological Therapeutics, 17, 15-19.21. Refshauge, K. M., Parry, S., Shirley, D., Larsen, D., Rivett, D. A., & Boland, R. (2002). Professionalresponsibility in relation to cervical spine manipulation. Australian Journal of Physiotherapy, 48, 171-179.22. Rivett, D. A. (2004). Adverse effects of cervical manipulative therapy. In J. D. Boyling & G. A. Jull (Eds.),Grieve’s Modern Manual Therapy of the Vertebral Column (3 rd ed., pp. 533-549). Edinburgh: ChurchillLivingstone.23. Rivett, D. A. (2004). The vertebral artery and vertebrobasilar insufficiency. In J. D. Boyling & G. A. Jull(Eds.), Grieve’s Modern Manual Therapy of the Vertebral Column (3 rd ed., pp. 257-273). Edinburgh:Churchill Livingstone.24. Rivett, D. A., Sharples, K. J., & Milburn, P. D. (1999). Effect of pre-manipulative tests on vertebral arteryand internal carotid artery blood flow: A pilot study. Journal of Manipulative and PhysiologicalTherapeutics, 22, 368-375.25. Rivett, D., Sharples, K., & Milburn, P. (2000). Vertebral artery blood flow during pre-manipulative testingof the cervical spine. Proceedings of the International Federation of Orthopaedic and ManipulativeTherapists Conference (pp. 387-390). Perth: International Federation of Orthopaedic and ManipulativeTherapists.26. Rivett, D. A., Thomas, L., & Bolton, P. (2005). Pre-manipulative testing: Where do we go from here?New Zealand Journal of Physiotherapy, 33, 78-84.27. Sim, J. (1996). Informed consent and manual therapy. Manual Therapy, 2, 104-106.28. Stevens, A. (1991). Functional Doppler sonography of the vertebral artery and some considerationsabout manual techniques. Journal of Manual Medicine, 6, 102-105.29. Thanvi, B., Munshi, S. K., Dawson, S. L., & Robinson, T. G. (2005). Carotid and vertebral arterydissection syndromes. Postgraduate Medical Journal, 81, 383-388.30. Thiel, H., & Rix, G. (2004). Is it time to stop functional pre-manipulative testing of the cervical spine?Manual Therapy, 10, 154-158.31. Thiel, H. W., Wallace, K., Donat, J., & Yong-Hing, K. (1994). Effect of various head and neck positionson vertebral artery blood flow. Clinical Biomechanics, 9, 105-110.32. Van der Velde, G. M. (1999). Benign paroxysmal positional vertigo. Part 1: Background and clinicalpresentation. Journal of the Canadian Chiropractic Association, 43, 31-40.33. Zaina, C., Grant, R., Johnson, C., Dansie, B., Taylor, J., & Spyropolous, P. (2003). The effect of cervicalrotation on blood flow in the contralateral vertebral artery. Manual Therapy, 8, 103-109.APA Clinical Guidelines ©APA 2006 Page 13 of 14for Assessing Vertebrobasilar Insufficiencyin the Management of Cervical Spine Disorders

APA Clinical GuidelinesAppendix 4AcknowledgementsThe APA and MPA wish to acknowledge the following individuals for contributing their time and expertise inthe development of this revised document:Dr Darren RivettDr Debra ShirleyDr Mary MagareyDr Kathryn RefshaugeDr Elizabeth EllisMcKean and ParkMichael RyanKirsty GreenwoodAuthorAssociate Professor, The University of NewcastleChair, MPA Academic and Professional StandardsCommitteeAuthor and Project ManagerLecturer, The University of SydneyFormer MPA National ChairAuthorSenior Lecturer, University of South AustraliaAuthorProfessor, The University of SydneyConsultantLawyers and ConsultantsMPA National ChairMPA National ManagerMPA members who participated in the focus groups and surveyThe individuals and organisations who contributed to the original APA Clinical Guidelines for PremanipulativeProcedures for the Cervical Spine (2000) are also acknowledged.APA Clinical Guidelines ©APA 2006 Page 14 of 14for Assessing Vertebrobasilar Insufficiencyin the Management of Cervical Spine Disorders