Clinical Diagnosis of Vertebrobasilar

Insufficiency: Residents Case Problem

Skulpan Asavasopon, MPT, OCS 1
John Jankoski, MPT, NCS, OCS 1
Joseph J. Godges, DPT, MA, OCS 2

Study Design: Residents case problem. vertigo and visual disturbances

Background: Vertigo and visual disturbances are common symptoms associated with stemming from vascular causes is
vertebrobasilar insufficiency (VBI), but the physical examination procedures to verify the existence scarce.16
of VBI have not been validated in the literature. The objective of this residents case problem is to The vertebral and basilar arter-
demonstrate how a patients complaint of vertigo and visual disturbances, combined with positive
ies supply blood to the pons, me-
clinical examination findings, can be a potential medical screening tool for VBI.
Diagnosis: The patient in this report was initially referred to physical therapy for neck pain.
dulla, cerebellum, mesencephalon,
However, the patients chief concerns identified during the history were (1) vertigo, (2) visual thalamus, occipital lobes, and the
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disturbances, (3) headache, and (4) right shoulder region pain. Clinical VBI tests were performed, central and peripheral vestibular
whereby the patients vertigo and visual disturbances were reproduced with cervical spine system.32,33 Disruption of normal
extension. The patient was sent back to the referring physician to be evaluated for possible VBI. blood flow in this area can pro-
Diagnostic imaging tests were ordered. Carotid ultrasound revealed 80% to 90% stenosis in the duce any of the following symp-
proximal left internal carotid artery, and magnetic resonance angiography of the extracerebral toms: nausea, vertigo and syncope,
vessels showed greater than 90% stenosis of the left internal carotid artery. and swallowing, speech, balance,
Copyright 2005 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Discussion: VBI may be present in patients with subjective reports of vertigo and visual auditor y, and visual distur-
disturbances that are reproduced with VBI physical examination procedures. J Orthop Sports Phys bances.4,8,13 Inadequate perfusion
Ther 2005;35:645-650.
to these areas of the brain can
Key Words: cervical spine, direct access, neck, primary care, vertebral artery produce symptoms that usually
have a rapid onset, vary in dura-
tion and frequency, and may occur

S
creening patients for potentially serious medical conditions is
in isolation or in some combina-
one of the most important components of a physical thera-
tion with one another.10,11
pists examination. It should not be assumed that a patient has Retrospective studies have re-

R E S I D E N T S C A S E P R O B L E M
undergone adequate medical screening, despite referral from
Journal of Orthopaedic & Sports Physical Therapy

ported that isolated episodes of

other health care providers. Patients who present with neck vertigo (sudden onset, lasting min-
pain, vertigo, and associated visual disturbances can be a challenging utes) can be a manifestation of
evaluation for a physical therapist because of the wide array of cerebral ischemia, which can pre-
peripheral and central causes.32,33,34 Differential diagnosis of these cede neurological symptoms by
symptoms may include, but not be limited to, cervicogenic dizziness,
months.10,11 In addition, visual dis-
benign paroxysmal positional vertigo, perilymphatic fistula, vestibular turbances are the most frequently
neuritis, labyrinthitis, hyperventilation, ototoxicity, Menieres disease, reported symptom associated with
orthostatic hypotension, and vertebrobasilar insufficiency (VBI).32,33,34,37 vertigo caused by altered vertebral
Screening patients for cerebral ischemia, specifically VBI, as the primary
artery blood flow.10,11,20,21 Unfor-
cause of their symptoms remains a difficult clinical decision for physical tunately, VBI is not a benign con-
therapists, because evidence-based guidelines for evaluating patients with dition and can eventually develop
into a cerebral or brainstem
ischemia, leading to severe mor-
1
Clinical Faculty, Kaiser Permanente Southern California, Orthopaedic Physical Therapy Residency, Los bidity or death.10,11,13,20,26
Angeles, CA. Such evidence suggests it may
2
Coordinator, Kaiser Permanente Southern California, Clinical Residency and Fellowship Programs, Los be advisable for practitioners to
Angeles, CA.
Address correspondence to Skulpan Asavasopon, Kaiser Permanente Medical Center, 1526 North appreciate that vertigo and visual
Edgemont Street, 4th Floor, Los Angeles, CA 90027. E-mail: Skulpan.X.Asavasopon@kp.org changes associated with a patients

Journal of Orthopaedic & Sports Physical Therapy 645

 neck pain may be potential indicators of VBI. How-
ever, the risk factors from a patients history leading
to suspicion of VBI have not been clearly identi-
fied.7,13,17,19,31 In an effort to identify patients at risk
for potential VBI, the Australian Physiotherapy Asso-
ciation (APA) in 1988 approved,1 and has since
revised,24 a protocol for premanipulative testing of
the cervical spine. The first aspect of the APA
guidelines involves the subjective examination, in
which a screening questionnaire is used to ascertain
the presence of symptoms suggestive of VBI, such as
vertigo, visual disturbances, syncope, disarthria,
dysphagia, nausea, and headaches.24 Although, in
some instances, an acute onset of neck pain with or
without headache can be the only manifestation of
vertebrobasilar ischemia secondary to dissection of
the vertebral artery.19,31 In addition, the progression
of neurological deficits associated with a vertebral or
carotid artery ischemic event can take hours to weeks
to appear.17,19
The physical examination portion of VBI screening
involves placing and holding the patients head in
several positions while monitoring for signs and
symptoms of VBI.23,25 If the subjective symptoms
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associated with VBI are provoked during or after the
physical examination procedure, then physical
therapy intervention and especially cervical spine
manipulation are considered to be contraindicated.1
However, 27 patients who developed cerebrovascular
Copyright 2005 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
accidents following cervical spinal manipulative pro-
cedures showed no adverse response to VBI physical
examination screening procedures before the ma-
nipulation.13 Thus, while the use of screening proto-
cols to assess VBI is advocated,24 the sensitivity and
specificity of these protocols are poor.6,12,13,22,29
Assessment of the vertebrobasilar circulatory system
and detection of occlusive disease in this area can be
done with imaging studies. Ultrasound imaging is a
Journal of Orthopaedic & Sports Physical Therapy
valid diagnostic tool for detection of carotid
stenosis.34 Magnetic resonance angiography (MRA)
has also been shown to have excellent sensitivity and
specificity in picking up distal vertebral artery pa-
thologies.30 Nevertheless, evaluating the smaller
branches of the vertebrobasilar circulatory system
remains limited even with these imaging studies.2
VBI is considered to be a rare but unpredictable
condition that is not easily detected from data col-
lected during the history and physical examination.13
In the absence of clear evidence, a reasonable ap-
proach is to err on the side of avoiding harm. The
purpose of this residents case problem is to describe
a case where the patients history and physical
examination suggested the presence of VBI, which
was verified with diagnostic imaging. This case also
serves to demonstrate appropriate measures taken for
a patient with clinical findings consistent with VBI.
646
DIAGNOSIS
History
The patient was a 63-year-old female referred to
physical therapy by a family practice physician with a
diagnosis of neck pain. The referral requested the
physical therapist to treat this diagnosis by addressing
stiffness and posture.
During the patients initial physical therapy visit,
the following information was ascertained. The pa-
tient was currently employed as a property manager.
The patients past medical history was significant for
hypertension, hyperlipidemia, and an uncomplicated
surgery for a hiatal hernia. Approximately 1 month
after the hiatal surgery she experienced intermittent
vertigo, which occurred while lying down and sitting
up in bed. After visiting a physician, she was diag-
nosed with benign paroxysmal positional vertigo
(BPPV) and was treated with meclizine HCl. No prior
history of trauma was reported.
The patient reported that the vertigo had contin-
ued for another week and progressed to the point at
which turning her head to the right caused intermit-
tent vertigo as well. The physician requested an
audiogram to assess for inner ear disorders. Lesions
to the inner ear and vestibulocochlear nerve (cranial
nerve VIII) can produce vertigo along with auditory
symptoms such as hearing loss, tinnitus, sensation of
pressure or fullness in the ear, or ear pain.3,37 The
patient was found to have asymmetrical hearing loss,
but this loss was considered within normal limits. The
result of the audiogram suggested that inner ear
pathology was not the cause of the patients symp-
toms.
At a subsequent visit to a physician approximately 5
months after the initial onset of vertigo the patient
complained of head stuffiness, tiredness, and neck
pain, and it was at this time that a referral to
physical therapy was made.
The patient was seen in physical therapy 4 days
later. During the subjective evaluation the patient
identified the following 4 complaints: (1) intermittent
vertigo lasting approximately 1 minute when turning
the head to the right, (2) visual changes, described as
black spots and distortion in her right eye,
which could last up to a half hour and were
reportedly becoming more frequent, (3) occasional
right frontal-occipital area headaches, and (4) inter-
mittent right shoulder area pain.
Medications taken at this time were ibuprofen for
headache, and triamterine, and conjugated estrogens
for hypertension.
Physical Examination
The patient did not experience any of the afore-
mentioned complaints while sitting upright during
the subjective examination. Given the history of
J Orthop Sports Phys Ther Volume 35 Number 10 October 2005

FIGURE 1. Vertebrobasilar insufficiency screening procedure: end
range cervical spine rotation with the patient supine.
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Copyright 2005 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
FIGURE 2. Vertebrobasilar insufficiency screening procedure: end
range cervical spine extension with the patient supine.
hypertension and complaints of headaches, the pa-
tients blood pressure was measured and found to be
Journal of Orthopaedic & Sports Physical Therapy
130/70. Active cervical range of motion was then
assessed in a sitting position. Active cervical move-
ments were observed to be within normal limits
although specific goniometric measurements were
not taken. The patient did report a pulling sensa- tions of her neck and to monitor any changes or
tion on the right side of the neck at the end ranges
of flexion, left rotation, and left side bending. Upon
returning to a midline head position the pulling
sensation had resolved for all the provocative move-
ments. No other symptoms were reported with active
cervical movements.
An attempt was then made to detect the existence
of VBI as a possible cause of the patients vertigo,
visual disturbances, and neck pain. The APA protocol
for vertebral artery testing was used.24 Initial testing
using this protocol includes sustained end range
rotation only, performed either in a supine or sitting
position. In addition to cervical rotation, cervical
J Orthop Sports Phys Ther Volume 35 Number 10 October 2005
extension can be added to the examination, with
continual questioning about provocation of VBI-
related symptoms.
In this patient, the physical examination proce-
dures were performed with the patient in supine.
The patients head was supported by the therapist in
a neutral position, and baseline resting symptoms of
vertigo, visual disturbances, and headache were ab-
sent. The patients head was passively turned into
right rotation and held at end range for 30 seconds
while the therapist monitored for symptoms of VBI
(Figure 1). The patients head was returned to
neutral and remained in this position for 30 seconds
to allow for a potential latent response. No symptoms
were provoked, and nystagmus was not observed with
this part of the protocol. The same procedure and
results were found for left cervical rotation. When the
patients cervical spine was passively placed into
extension, familiar symptoms of vertigo were pro-
duced and persisted as long as the head was main-
tained in extension (Figure 2). The patients head
was immediately repositioned into neutral and re-
mained there (approximately 60 seconds) until the
symptoms abated. When the cervical extension posi-
tion was repeated, the patient reported having symp-
toms of visual disturbance, specifically seeing black
spots. The patients head was again repositioned to
neutral and supported on the treatment table until
the symptoms resolved. The remainder of the VBI
screening protocol was not performed because of the
possible nature of her problem, namely VBI. Once
these symptoms resolved, the patient was assisted into
an upright sitting position.
A written copy of the physical therapy evaluation,
including an assessment of possible vertebrobasilar
insufficiency, was given to the patient for her previ-
ously scheduled medical appointment the following
day. An attempt was also made to reach the physician
by phone, but because he was unavailable, a detailed
R E S I D E N T S C A S E P R O B L E M
message was left on the physicians voicemail system
to inform him of the significant findings. The patient
was advised to delay further physical therapy services
until receiving clearance by her physician. She was
also advised to avoid any symptom-provoking posi-
occurrences of any signs and symptoms she might
encounter.
Diagnostic Testing
Shortly after a follow-up visit with her physician,
cervical spine radiographs, carotid ultrasound, mag-
netic resonance angiogram (MRA), and magnetic
resonance imaging (MRI) were ordered. Cervical
spine radiographs and MRI yielded normal results.
Carotid ultrasound revealed 80% to 90% stenosis in
the proximal left internal carotid artery. MRA find-
ings demonstrated greater than 90% stenosis of the
same artery. A medical diagnosis of left carotid artery
647
 stenosis was given, and a surgical decision to perform
an endarterectomy was made to correct the occlu-
sion.
DISCUSSION
This case report describes a 63-year-old woman with
chief complaints of intermittent vertigo, visual distur-
bances, occasional headache, and right-sided neck
and shoulder pain. Although the referral requested
the physical therapist to treat her neck and shoulder
symptoms by addressing stiffness and posture,
evaluation of the symptoms of vertigo, visual distur-
bances, and headache carried a higher priority than
evaluation of her neck and shoulder pain. To discern
whether the patients complaints were of vascular,
vestibular, or cervicogenic origin a differential diag-
nostic approach was used. Recognizing that VBI can
potentially cause all or some of the patients symp-
toms, the clinician decided to screen for this medical
condition. If the examination findings were not
consistent with VBI, the clinician would have consid-
ered other vascular disorders that could cause vertigo
and visual disturbances, such as postural hypotension
or cardiac abnormalities.
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Reproducing the patients vertigo and visual hallu-
cination of black spots with the passive cervical
extension portion of the physical examination sug-
gests VBI as a possible cause of the patients
symtoms.1,24 Although, symptoms of vertigo that are
associated with head and neck movements can have a
Copyright 2005 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
vestibular or cervicogenic origin as well. Among these
differential diagnoses, VBI has the potential to de-
velop into the most serious condition and therefore,
should be evaluated first. An attempt to rule in or
rule out VBI as the primary diagnosis was made by
using a provocative screening exam despite the poor
sensitivity and specificity associated with such
tests.6,12,13,22 Although, exposing the patient to this
provocative physical examination procedure may have
Journal of Orthopaedic & Sports Physical Therapy
theoretically increased the potential for causing
harm, this potential was minimized by closely moni-
toring the patient during the procedure. The poten-
tial benefits of eliciting positive results that expedited
the patients scheduling of the definitive diagnostic
imaging were felt to outweigh the risks. Additionally,
there is no evidence in the literature that the
performance of such a test is harmful. Because the
test was found to be positive, along with the patients
subjective examination findings, the decision was
made to cease further physical therapy examination
or intervention until the diagnosis of VBI could be
ruled out with certainty. Had the test been negative,
the authors would have considered cautiously examin-
ing the patient for musculoskeletal impairments in
addition to referring the patient back to her physi-
cian.
Failure to acknowledge the potential of false nega-
tive results when using VBI screening tests can lead to
648
serious errors in the clinical decision-making process
and unwanted complications. In a retrospective study
of 64 patients who sustained complications related to
cerebrovascular ischemia following cervical spine ma-
nipulation, Haldeman and associates14 reported that
none of the patients demonstrated adverse responses
to screening tests believed to assess the patency of the
vertebral artery. False-negative results were also re-
ported in Cote et als6 study of vertebral artery blood
flow with a extension-rotation screening test. Despite
having VBI signs and symptoms when placed in an
extended-rotated position, blood flow measures
through the vertebral artery did not decrease, as
measured with Doppler ultrasonography.6 Two pos-
sible explanations for false-negative results during
VBI screening tests are an inadequate occlusion of
the vertebral artery and compensation by the collat-
eral circulation.36 If the vertebral artery is not com-
pletely occluded during the provocative test position
(ie, passive cervical end range position is not
achieved), then perfusion to cortical tissue is main-
tained. Collateral circulation through larger (internal
and external carotids) or smaller (anterior and poste-
rior communicating arteries) vessels can potentially
provide adequate blood supply during the occlusion
of the vertebral artery screening tests. Indeed, it has
been suggested that VBI screening tests essentially
evaluate the status of collateral circulation in the
presence of a compromised vertebral artery.29 The
results of this case report support this premise. Our
patient demonstrated greater than 90% stenosis of
the left internal carotid artery during MRA. Perhaps
this amount of occlusion in the left carotid artery was
sufficient to prevent adequate perfusion of brain
tissue while the patients head was held at an end-
range extension position.
Confirmation of suspected cerebral ischemia was
confirmed with carotid ultrasound and MRA. The
importance of being able to convey our subjective
and objective examination findings to the patients
physician was pivotal in facilitating the patient
through the appropriate channels of care. It is
important to be well versed in the clinical decision
making process when patients present with vertigo or
visual disturbances. Being knowledgeable about ap-
propriate diagnostic studies and medical management
(medications, surgical options) is essential for effec-
tive communication with other health care practitio-
ners.
Having a working knowledge base of the potential
differential diagnoses is also essential in the delivery
of standard care. Because vertigo and visual distur-
bance symptoms are also associated with vestibular,
vascular, or cervicogenic disorders, the authors did
attempt to collect data in the physical examination to
at least rule in or rule out such disorders. Keeping in
mind that the priority of vascular compromise was of
primary concern, the authors felt the need to justify
J Orthop Sports Phys Ther Volume 35 Number 10 October 2005
 that such symptoms of vertigo could potentially un-
derlie and overlap objective data pointing to
vestibular or cervical origins. It was recognized that
vestibular disorders can stem from vascular compro-
mise of the vertebrobasilar artery system.11 Differenti-
ating vascular compromise from benign paroxysmal
positional vertigo (BPPV) was done by examining the
characteristics of the patients dizziness and other
symptoms experienced during the vertebral artery
test protocol. BPPV produces episodes of vertigo
lasting less than 1 minute and is always induced by a
specific head movement in relation to gravity (ie,
lying down, looking up, or rolling onto ones side).2,9
The patient described her episodes of vertigo as
lasting about 1 minute, which were produced with
cervical rotation alone. With BPPV the intensity of
vertigo should gradually decrease when the patient is
placed and held in a provocative position (Dix-
Hallpike9). Familiar symptoms of vertigo were pro-
duced but persistent when the patient was placed and
held in a position of cervical extension. When this
condition was repeated the patient experienced visual
changes (specifically, the patient saw black spots).
Although the presence of persistent vertigo and visual
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disturbances with sustained cervical extension are not
definitive diagnostic signs, they did help to differenti-
ate the possible cause of these symptoms as vascular
compromise of the vertebrobasilar artery rather than
BPPV or a cervicogenic problem. Visual disturbances
Copyright 2005 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
are a reported neurological symptom associated with
cerebrovascular ischemia following manipulation and
the use of screening tests.6,13,17
To help determine if isolated symptoms of vertigo
(or posturally induced vertigo or balance distur-
bances) come from a lesion in the vestibular laby-
rinth rather than the brainstem/cerebellum area,
clinicians can perform a vestibular evaluation, which
includes caloric testing. Findings of vestibular decruit-
Journal of Orthopaedic & Sports Physical Therapy
ment and hyperactive caloric responses have been
found to be sensitive (86%) to identify patients
with impedance of blood flow to the vertebral artery
or infarcts in the brainstem/cerebellum region.21
The patients medical history was significant for
hyperlipidemia and hypertension. Hyperlipidemia
and hypertension, along with heart disease, diabetes,
carotid disease, smoking, and alcoholism, have been
identified as risk factors in patients who experience
symptoms associated with VBI.21 Ohashi et al27 stud-
ied relationships between abnormal blood pressure
and symptoms of vertigo, dizziness, and
disequilibrium. They found that peripheral vestibular
disease was associated with hypotension, while central
nervous system disorders were linked to hypertension.
These 2 risk factors of hypertension and
hyperlipidemia provide further support for an under-
lying vascular origin to the patients symptoms. The
authors hypothesized that the accompanying symp-
J Orthop Sports Phys Ther Volume 35 Number 10 October 2005
toms of headache and visual changes may be a result
of vascular compromise as well.
The authors emphasize that the patient would have
been referred back to her physician regardless of the
physical examination findings. The subjective history
alone warranted increased attention for the potential
of VBI, and the basis of the decision-making process
was not based solely on the physical examination.
CONCLUSION
This residents case problem presents a patient with
complaints of vertigo, headache, and visual changes,
which were consistent with VBI and later confirmed
with carotid ultrasound and MRA. Episodic vertigo,
especially when lasting more than 1 minute, occur-
ring in isolation or with other associated VBI symp-
toms, should be considered a potential medical-
screening red flag, and should increase the index of
suspicion of vascular insufficiency. Further research is
needed to validate the use of VBI risk factors and
physical examination procedures. Although the value
of cervical extension and/or rotation screening pro-
cedures is questionable at the present time, positive
findings with these tests should warrant caution.
Patients who exhibit hallmark symptoms and signs of
VBI should be referred to their physician for further
diagnostic testing.
ACKNOWLEDGMENTS
The authors would like to acknowledge Chris
Powers, PT, PhD for his contributions as a consultant
and reviewer of this report.
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J Orthop Sports Phys Ther Volume 35 Number 10 October 2005