SomaSimple Discussion Lists  

Go Back   SomaSimple Discussion Lists > Physiotherapy / Physical Therapy / Manual Therapy / Bodywork > Clinical Reasoning
Albums Quiz PubMed Gray's Anatomy Tags Online Journals Statistics

Notices

Clinical Reasoning Typical cases are discussed there. The cases are brought by practioners.

Reply
 
Thread Tools Display Modes
Old 19-11-2010, 09:26 AM   #1
kongen
Senior Member
 
Join Date: Jul 2006
Location: Sweden
Age: 39
Posts: 558
Thanks: 97
Thanked 36 Times in 15 Posts
Default Verterbral artery dissection

Hi!

I am curious if anyone has actually had a patient in front of them with a suspected ongoing vertebral artery dissection, before obvious neurological signs has developed? An actual VAD that was later confirmed. If so, what was the presenting symptoms in that case?
__________________
Anders.
"There is nothing so practical as a good theory." -Kurt Lewin
kongen is offline   Reply With Quote
Old 19-11-2010, 01:08 PM   #2
Bas Asselbergs
Physiotherapist
 
Bas Asselbergs's Avatar
 
Join Date: Jul 2004
Location: Canada
Age: 62
Posts: 4,609
Thanks: 1,972
Thanked 1,496 Times in 655 Posts
Default

Anders, "before" neurological signs had developed? A VAD that was discovered by chance you mean? Because how else would one know there was a VAD? After all, symptoms of VAD are part of the clinical signs we look for, aren't they?

No, never saw one. Never had any VAD case.
__________________
We don't see things as they are, we see things as WE are - Anais Nin
I suppose it's easier to believe something than it is to understand it.
Cmdr. Chris Hadfield on rise of poor / pseudo science

Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

We don't need a body to feel a body. Ronald Melzack

Last edited by Bas Asselbergs; 19-11-2010 at 01:58 PM. Reason: typos
Bas Asselbergs is online now   Reply With Quote
Old 19-11-2010, 01:12 PM   #3
Diane
Human Primate Social Groomer and Neuroelastician
 
Diane's Avatar
 
Join Date: Mar 2004
Location: Weyburn Sask.
Posts: 23,021
Thanks: 3,198
Thanked 6,388 Times in 2,904 Posts
Default

How does anyone pick up on these kinds of things before the fact? My understanding is that it's hard to tell, which is why those who feel invulnerable to the possibility continue to produce them and those who are sickened by the very thought wouldn't go anywhere near them with a ten-foot disinfected barge pole.
__________________
Diane
www.dermoneuromodulation.com
SensibleSolutionsPhysiotherapy
HumanAntiGravitySuit blog
Neurotonics PT Teamblog
Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
Canadian Physiotherapy Association Pain Science Division Facebook page
@PainPhysiosCan
WCPT PhysiotherapyPainNetwork on Facebook
@WCPTPTPN
Neuroscience and Pain Science for Manual PTs Facebook page

@dfjpt
SomaSimple on Facebook
@somasimple

"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

"Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire
Diane is offline   Reply With Quote
Old 19-11-2010, 02:36 PM   #4
John W
"Mean Poopy-Pants" Club Founding Member
 
John W's Avatar
 
Join Date: Sep 2006
Location: Mandeville, LA
Age: 49
Posts: 6,210
Thanks: 1,828
Thanked 3,050 Times in 1,201 Posts
Default

Anders,

There's also the very real possibility of vertebral artery hypoplasia, which has been shown to be a risk factor for vertebrobasilar infarction, and which can only be diagnosed via arteriogram of the VB circulation (see the free access article attached).

I've got my 10-foot barge pole always at the ready.
__________________
John Ware, PT
Fellow of the American Academy of Orthopedic Manual Physical Therapists
"Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
“If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
be carried on to success.” -The Analects of Confucius, Book 13, Verse 3
John W is offline   Reply With Quote
Old 19-11-2010, 02:54 PM   #5
kongen
Senior Member
 
Join Date: Jul 2006
Location: Sweden
Age: 39
Posts: 558
Thanks: 97
Thanked 36 Times in 15 Posts
Default

Quote:
Originally Posted by Bas Asselbergs View Post
Anders, "before" neurological signs had developed? A VAD that was discovered by chance you mean? Because how else would one know there was a VAD? After all, symptoms of VAD are part of the clinical signs we look for, aren't they?

No, never saw one. Never had any VAD case.
If my understanding is correct, a VAD in it's early stages can present with occipital pain, neck pain, neck stiffness. That is before any ischemia, occlusion or infarction has led to neurological symptoms. I guess my question is, without hard neurological signs, are there any other clinical signs or something about the history that could lead to a suspicion of ongoing VAD?
__________________
Anders.
"There is nothing so practical as a good theory." -Kurt Lewin
kongen is offline   Reply With Quote
Old 19-11-2010, 03:20 PM   #6
John W
"Mean Poopy-Pants" Club Founding Member
 
John W's Avatar
 
Join Date: Sep 2006
Location: Mandeville, LA
Age: 49
Posts: 6,210
Thanks: 1,828
Thanked 3,050 Times in 1,201 Posts
Default

I think the point is that it is extremely difficult,if not impossible, to differentiate mechanical neck pain from symptomatic VAD. Perhaps employing a careful distinction between visceral tissue damage-mediated pain and mechanical pain, which should respond significantly to movement or position, might help. But the vascular structures in question will certainly be prone to movement and positional stresses that are similar to the mechanical tissues, so I'm not sure that this distinction will be helpful here.

I suppose some VBI tests might be employed, although they haven't been shown to be very sensitive, and there may be some unnecessary risks associated with performing them.

If the patient does not respond to careful manual and movement therapies within a reasonable time frame, then, rather than proceed with more aggressive techniques (which is what some clinicians will do), then the prudent course might be to refer back for more medical work up to rule out VAD.
__________________
John Ware, PT
Fellow of the American Academy of Orthopedic Manual Physical Therapists
"Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
“If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
be carried on to success.” -The Analects of Confucius, Book 13, Verse 3
John W is offline   Reply With Quote
Old 19-11-2010, 05:09 PM   #7
Bas Asselbergs
Physiotherapist
 
Bas Asselbergs's Avatar
 
Join Date: Jul 2004
Location: Canada
Age: 62
Posts: 4,609
Thanks: 1,972
Thanked 1,496 Times in 655 Posts
Default

Sorry Anders. I considered pain a neurological sign and symptom.

I agree with John - not a heck of a lot to be sure beforehand.
__________________
We don't see things as they are, we see things as WE are - Anais Nin
I suppose it's easier to believe something than it is to understand it.
Cmdr. Chris Hadfield on rise of poor / pseudo science

Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

We don't need a body to feel a body. Ronald Melzack
Bas Asselbergs is online now   Reply With Quote
Old 19-11-2010, 08:58 PM   #8
nari
NeuroNut Evangelist
 
nari's Avatar
 
Join Date: Mar 2004
Location: ACT Aust
Posts: 8,681
Thanks: 2,001
Thanked 610 Times in 438 Posts
Default

I think it would be impossible to determine the difference between a potential VAD and the more usual pain and stiffness presentation. Even if there was a subtle sign of a VAD about to occur, it is not worth the risk of doing anything which stresses the cervical spine in any way.

Which is where DNM comes in, it cannot stress or harm in any way. If there's no positive response, I'd consider a referral back for more information on the matter.
Come to think of it, we all must have done stressful things to patients whose VA was at borderline patency and got away with it. Particularly the chiros...

Nari
nari is offline   Reply With Quote
Old 19-11-2010, 09:15 PM   #9
kongen
Senior Member
 
Join Date: Jul 2006
Location: Sweden
Age: 39
Posts: 558
Thanks: 97
Thanked 36 Times in 15 Posts
Default

John,

That is my reasoning aswell, and one that I have applied to an ongoing case presentation. The signs, symptoms and lack of response to gentle treatment does not add up in my book. Getting an MD to take my concerns seriously though.. All I can do is refer. I will update this thread.

Bas,

I see your point about using the correct terminology.
__________________
Anders.
"There is nothing so practical as a good theory." -Kurt Lewin
kongen is offline   Reply With Quote
Old 22-11-2010, 07:47 PM   #10
kongen
Senior Member
 
Join Date: Jul 2006
Location: Sweden
Age: 39
Posts: 558
Thanks: 97
Thanked 36 Times in 15 Posts
Default

The patient in question did recieve a thorough medical check up today, all clear.
__________________
Anders.
"There is nothing so practical as a good theory." -Kurt Lewin
kongen is offline   Reply With Quote
Old 22-11-2010, 11:29 PM   #11
Frédéric
Swaying against the breeze
 
Frédéric's Avatar
 
Join Date: Sep 2008
Location: Prévost Québec
Age: 38
Posts: 1,977
Thanks: 207
Thanked 219 Times in 98 Posts
Default

I had a pt once that could have had the signs and symptoms for a VA issue after a MVA.

I even convinced the neurologist at the time to do the angio MRI and another angio test I can't recall. That was some years ago.

She had difficulty swallowing, tinnitus, hypoesthesia to the left side of the face, a change in her voice timbre. She had upper neck pain and headaches plus a focal dystonia following the accident. Dizziness was present. The VBI test was increasing some of the symptoms, mostly pain and dizziness. There where severe hypertonia in her sub-occipital muscles and sterno muscles from what I recall.

All the tests turned out negative. Her symptoms only started a few days after the accident soon after her family member had told her she could have died in such an accident. (she made a lot of tumbling at hight speed on the highway.

Now that I look back, I think she was highly sensitized and perhaps had some disseminated small neuropathies, but no VAD.
__________________
Frédéric Wellens, pht
«We often refuse to accept an idea merely because the tone of voice in which it has been expressed is unsympathetic to us.»
«
Those who cannot understand how to put their thoughts on ice should not enter into the heat of debate.
»
Friedrich Nietzsche
www.physioaxis.ca
chroniquesdedouleur blog
Frédéric is offline   Reply With Quote
Reply

Bookmarks

Thread Tools
Display Modes

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is On
HTML code is Off

Forum Jump

Similar Threads
Thread Thread Starter Forum Replies Last Post
Cadaver Dissection - Diane Jacobs - Musculocutaneous Nerve I Robot The Wind Rose 1 03-07-2008 05:42 PM
Blocked femoral artery rsder Clinical Reasoning 12 23-12-2005 09:25 AM


All times are GMT +2. The time now is 05:51 PM.


Powered by vBulletin® Version 3.8.8
Copyright ©2000 - 2014, vBulletin Solutions, Inc.
SomaSimple © 2004 - 2014