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Special tests of the upper cervical spine. The modified sharp purser test, alar ligament stability test, tectorial membrane, posterior atlanto-occipital joint, vertebrobasilar insufficiency (VBI) test, and Wallenberg's position. The reliability, specificity, sensitivity, validity, safety, and screening for neck pain, VBI, and cervical spine instability. 

Special Tests: Upper Cervical Spine Instability and Vertebrobasilar Insufficiency (VBI)

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Tectorial Membrane and Posterior Atlanto-occipital Membrane Test

Anterior Stability Test of the Atlanto-Occipital Joint

Vertebrobasilar Insufficiency (VBI) Test and Wallenberg's Position

Upper cervical spine instability and vertebrobasilar ischemia (VBI) are potentially serious issues that most commonly result from injury, some congenital disorders, and rarely, the degeneration of relevant tissues with the aging process. For example, Ehlers-Danlos Syndrome (EDS) is a connective tissue disorder that can result in laxity of the transverse ligament, tectororial membrane, or alar ligament, resulting in craniocervical instability and an increase in the risk symptoms like nerve root compression with axial rotation. Additionally, a fall that involves landing "on the neck", or a fall that involves a concussive force to the head, in rare cases can result in cervical spine injury that disrupts the connective tissue structures of the upper cervical spine or the dens of the axis. Unfortunately, this may initially result in only neck pain, despite surgical repair being necessary to prevent potential spinal cord injury. Note, there is no evidence that chiropractic care is a common cause of cervical instability or cervical injury, especially those injuries resulting from VBI (More information available in the course linked below). Although chronic neck pain can be an indicator of craniocervical instability and/or VBI, most often injury or diagnoses of congenital disorders precede these diagnoses. Special tests for these conditions have poor sensitivity, but high specificity, so their use as a screen is not recommended. The special tests for these conditions likely only have minimal utility to confirm a diagnosis indicated by prior history (head injury), testing (imaging), or symptomatology (neurological signs).

"Clear" the Patient/Client for Intervention:

 The gross majority of special tests are only helpful for clearing the patient for intervention, and do not have an impact on intervention selection. The Brookbush Institute is adamant that choosing interventions based on diagnosis is flawed logic, and that interventions should be selected based on the results of movement 

. However, some diagnoses imply physical interventions are not recommended, and referral for additional testing or alternative treatments is necessary. For example, cervical spine instability, craniocervical instability, ligament laxity, connective tissue rupture, symptoms of spinal cord compression, nerve root compression (irritable radiculopathy), etc., may imply that treatment should be postponed until further testing can be performed, and/or surgery is considered.

 Some special tests may indicate damage to tissues and suggest that certain targeted interventions are inappropriate. For example, the special tests in this course may indicate ligament laxity, clinical instability, cervical bracing (muscle spasm), pain with certain motions, etc. These results may indicate that cervical manipulations, cervical muscle stretching, or certain high-intensity exercises are not appropriate.

: A few of these special tests could be used like movement assessments. For example, assuming that the tests did not provoke symptoms associated with a positive result, stiffness and pain with motion may be indicative that 

 may be beneficial, findings of increased tissue density and/or muscle spasm may indicate 

 should be considered. And, findings of spinal instability (without additional symptoms) may indicate that cervical stabilization and 

 recommends that all clinical professionals are aware of these special tests (physical therapists, physical therapy assistants, chiropractors, occupational therapists, athletic trainers, etc.). It is recommended that VBI and/or upper cervical instability tests are performed if findings during the subjective examination imply that VBI or upper cervical instability may be contributing to a patient's condition, and/or if these tests have been mandated as a screening prior to manipulation by legislation, 3rd party payer, or a licensing boards that the professional relies on. However, the Brookbush Institute cannot recommend these tests as a valid, reliable, or accurate method for screening patients who may be at risk for a serious adverse event correlated with manipulation. Note, at all times, the clinician should use reason, rationale, and professional judgment, and err on the side of caution when performing any technique that may impart an unacceptable increase in risk.

For an introduction to Special Tests including definitions of specific terminology, what special tests measure, accuracy (specificity, sensitivity, reliability, etc.), how we chose the tests in each special test course lessons, and best practice recommendations:

Additional Special Tests for the Cervical Spine:

Special Tests: Cervical Radiculopathy, Cervicogenic Headache, and Canadian C-spine Rules

Risk of Adverse Events following Mobilization and Manipulation:

Joint Mobilizations and Manipulations: Risk of Adverse Events

Course Description: Special Tests: Upper Cervical Spine Instability and Vertebrobasilar Insufficiency (VBI)

Introduction

For an introduction to Special Tests including definitions of specific terminology, what special tests measure, how we chose the tests in these lessons, and best use, check out:

The special tests for upper cervical spine instability and vertebrobasilar ischemia (VBI) are under-studied. Many questions are unanswered regarding the reliability, specificity, sensitivity, and validity of these tests. Based on the criteria described in 

 some of these tests would not be included in this course; however, some organizations have called for these tests to be mandatory for the pre-screening of any patient who will receive high-velocity cervical manipulations as part of a treatment plan (10, 11).

The argument in favor of using these tests is focused on the potentially serious consequences of upper cervical instability and VBI, and the few documented cases of serious complications post cervical manipulation. It should be noted that the tests in this course demonstrate high specificity, based on limited research (4 - 9), and are recommended when subjective complaints infer that VBI or upper cervical instability may be an issue (e.g. myelopathy). Most clinicians would agree that identification of upper cervical instability and VBI in patients complaining of related symptoms is essential. However, the relationship between these symptoms and complications from cervical manipulations has been greatly exaggerated by some professionals.

A large survey study by Margarey et al. suggests that adverse effects post cervical manipulation reported by those using cervical manipulation/mobilization on a regular basis occur at a rate of about one per 1000 years of practice. This rate of occurrence suggests that less than 3% of all practicing manual therapists will have 1 serious incident in a 30-year career (11). Consideration should also be given to the positive predictive value (PPV), as rates this low may coincide with random chance, or the typical rate of rare pathologies not commonly associated with physical interventions such as cancer, embolism, or stroke. Although death and serious disability may seem to warrant testing regardless of the low rate of incidence, it is important to consider how sensitive a test would have to be to screen the incredibly rare incidents resulting in serious complications.

The second issue with using these tests as a pre-screen is whether these tests are sensitive. To date, the few studies available have demonstrated high specificity, but poor sensitivity (4 - 9). This suggests that a positive test is helpful for diagnosis, but that a negative test is little if any help for screening patients (i.e. there is a high probability of a false-negative). It is interesting that other special tests have been discarded due to low accuracy rates, but these tests are often recommended as screens despite low sensitivity.

Last, although these tests demonstrate validity for testing upper cervical instability and VBI (4 - 9), there are no studies to show that these issues are correlated with the rare complications noted post cervical manipulation. Studies correlating complications post cervical manipulation with VBI and instability are necessary to validate the use of these tests as a mandatory screen. Further, it would be unfortunate if the use of these tests resulted in an assumption of validity that prevented further study into causes more closely related to serious complications. For example, a correlation may be made between serious complications and vertebral artery aneurysm, atherosclerotic disease and emboli, osteophyte formation, and/or certain high amplitude techniques which result in more stretch to the vertebral artery. Studies should be designed to determine the factors associated with serious complications post cervical manipulation, and those studies may be used to develop more sensitive screening methods.

Alar Ligament Test

In summary, the Brookbush Institute recommends performing VBI and/or upper cervical instability tests if findings during the subjective examination imply that VBI or upper cervical instability may be contributing to a patient's condition, and/or if these tests have been mandated as a screen prior to manipulation by legislation, 3rd party payer, or a licensing boards that the professional relies on. However, the Brookbush Institute cannot recommend these tests as a valid, reliable, or accurate method for screening patients who may be at risk for a serious adverse event correlated with manipulation. Note, at all times, the clinician should use reason, rationale, and professional judgment, and err on the side of caution when performing any technique that may impart an unacceptable increase in risk.

Research Corner

Forward Head Posture

Upper Cervical Spine Stability Tests

The patient is asked to flex their neck and resting symptoms are assessed.

The examiner stands to the side of the patient and stabilizes C2 by using a pincer grip on the C2 spinous process.

The examiner then places the other hand on the forehead of the patient and gently applies an anterior to posterior force.

The amount of translation is assessed, and symptoms are assessed while the posterior force is being applied.

A positive test is a combination of myelopathic symptoms during flexion, a reduction of symptoms during posterior translation of the cranium on C2, and/or excessive motion of the cranium on C2.

The patient is asked to slightly flex their neck, increasing the stress on the alar ligament, and resting symptoms are assessed.

The examiner then places the other hand on the head and laterally flexes and rotates the patient's upper cervical spine.

The examiner attempts to feel the C2 spinous process move between the fingers with each tilt or rotation of the head.

A positive test is a failure to feel movement of the spinous process with lateral flexion or rotation of the upper cervical spine.

The examiner places the hand around the occipital bone with thumb and forefinger on or pointing toward, the mastoid processes.

The other hand is used to block the mid and lower cervical spine by grasping the spinous processes with a pincer-like grip from C3 to C5 or C6 (depending on the size of the examiner's hands).

The examiner then uses the hand around the occiput and mastoid process to create an upward and posterior force (traction and anterior to posterior glide of the skull).

A positive test is excessive motion of the occiput, C1 and/or C2

Posterior Atlanto-occipital Membrane Test

The examiner tests each of the atlanto-occipital joints separately (right and left).

The examiner places one thumb on a posterior surface (likely the transverse process) of C1.

With the other hand, a thumb is placed on the occiput superior to the other thumb on C1.

The examiner attempts to pull apart their thumbs, creating a traction force between C1 and the occiput.

A positive test is excessive motion between the occiput and C1

Anterior Stability Test of the Atlanto-occipital Joint

The examiner places their fingers under the occiput and locates the transverse process of C1 and C2 with the thumbs.

The examiner then slides the thumbs over the anterior surface of the transverse process.

The amount of motion is tested by simultaneously applying a downward (posterior) force on the transverse process while lifting the head with the fingers.

The test is considered positive if the motion reproduces myelopathic symptoms or the motion causes excessive displacement.

Dr. Brent Brookbush highlighting sections of the cervical spine

The patient is assessed for a history of symptoms associated with VBI during a subjective examination. If any symptoms are noted the patient is referred out for further testing.

If the subjective examination is negative for VBI symptoms, the patient is asked to assume a supine position.

The examiner then passively moves the patient into end-range cervical rotation (some texts note the addition of extension) and the position is held for 10 seconds.

Signs of VBI are assessed during this 10 second period: dizziness, double vision (diplopia), slurring words and problems speaking (dysphasia), problems swallowing (dysphagia), feeling faint or losing consciousness, nausea, and nystagmus.

The patient is returned to the neutral position and symptoms are assessed for an additional 10 seconds.

The examiner then repeats these steps on the opposite side.

If any VBI symptoms are noted during the test, the test is positive.

The examiner either guides or asks the patient to rotate and extend the head to one side.

The position is held for 30 seconds and the patient is assessed for signs of VBI: dizziness, double vision (diplopia), slurring words and problems speaking (dysphasia), problems swallowing (dysarthria), feeling faint or losing consciousness, nausea, and nystagmus.

Cook, C., & Hegedus, E. J. (2008). Orthopedic physical examination tests: an evidence-based approach.

Dutton's Orthopaedic examination, evaluation, and intervention

Uitvlugt, G., & Indenbaum, S. (1988). Clinical assessment of atlantoaxial instability using the sharp‐purser test. 

Arthritis & Rheumatism: Official Journal of the American College of Rheumatology

Cattrysse, E., Swinkels, R. A. H. M., Oostendorp, R. A. B., & Duquet, W. (1997). Upper cervical instability: are clinical tests reliable?. 

Hutting, N., Scholten-Peeters, G. G., Vijverman, V., Keesenberg, M. D., & Verhagen, A. P. (2013). Diagnostic accuracy of upper cervical spine instability tests: a systematic review. 

Forrester, G. A., & Barlas, P. (1999). Reliability and Validity of the Sharp-Purser Test in the Assessment of Atlanto-axial Instability in Patients with Rheumatoid Arthritis. 

Kaale, B. R., Krakenes, J., Albrektsen, G., & Wester, K. (2008). Clinical assessment techniques for detecting ligament and membrane injuries in the upper cervical spine region—a comparison with MRI results. 

Tectorial Membrane and Posterior Atlanto-occipital Membrane Test (6, 8)

Anterior Stability Test of the Atlanto-occipital Joint (8)

Cote, P., Kreitz, B. G., Cassidy, J. D., & Thiel, H. (1996). The validity of the extension-rotation test as a clinical screening procedure before neck manipulation: a secondary analysis. 

Journal of Manipulative and Physiological Therapeutics

Barker, S., Kesson, M., Ashmore, J., Turner, G., Conway, J., & Stevens, D. (2001). Guidance for pre-manipulative testing of the cervical spine. 

Magarey, M. E., Rebbeck, T., Coughlan, B., Grimmer, K., Rivett, D. A., & Refshauge, K. (2004). Pre-manipulative testing of the cervical spine review, revision and new clinical guidelines. 

 Boucher, P., & Robidoux, S. (2014). Lumbar disc herniation and cauda equina syndrome following spinal manipulative therapy: a review of six court decisions in Canada. 

Chaibi, A., & Russell, M. B. (2019). A risk–benefit assessment strategy to exclude cervical artery dissection in spinal manual-therapy: a comprehensive review. Annals of medicine, 51(2), 118-127.

 Mathews, J. A. (1969). Atlanto-axial subluxation in rheumatoid arthritis. Annals of the Rheumatic Diseases, 28(3), 260.

Bibliography

Questions, comments and criticisms welcome and encouraged

Special Tests: Upper Cervical Spine Instability and Vertebrobasilar Insufficiency (VBI)

Related Courses:

Course Description: Special Tests: Upper Cervical Spine Instability and Vertebrobasilar Insufficiency (VBI)

Introduction
1 Sub Section

Upper Cervical Spine Stability Tests

Anterior Stability Test of the Atlanto-occipital Joint

Vertebrobasilar Insufficiency (VBI) Test and Wallenberg's Position

Bibliography

Related Courses:

Comments

Guest

Special Tests: Upper Cervical Spine Instability and Vertebrobasilar Insufficiency (VBI)

Related Courses:

Course Description: Special Tests: Upper Cervical Spine Instability and Vertebrobasilar Insufficiency (VBI)

Introduction1 Sub Section

Upper Cervical Spine Stability Tests

Anterior Stability Test of the Atlanto-occipital Joint

Vertebrobasilar Insufficiency (VBI) Test and Wallenberg's Position

Bibliography

Related Courses:

Comments

Guest

Introduction
1 Sub Section