Dizziness In Orthopaedic Physical Therapy Practice: History And Physical Examination Page 21
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30proprioceptive acuity and vibration sense in the feet and
to the extension-rotation test with regards to latency,
ankles, which may contribute to dysequilibrium-type
non-accommodation, and non-habituation. However,
dizziness. Multisegmental deficits may indicate the need
findings on sustained cervical rotation alone are equally
for referral.
equivocal with significant decreases in vertebral artery
flow
or no effect on blood flow
or blood vol-
96-98,105,106
107
ume
. Indications for this test and implications of a
108
Vertebrobasilar Insuffi ciency Tests
clearly central neurological involvement are as described
De Kleyn-Nieuwenhuyse Test
for the extension-rotation test.
Terrett
noted that the original test description had
13
Hautant Test
postulated decreased or even absent vertebral artery
blood flow based on cadaver perfusion studies in differ-
This test is used for differential diagnosis of vestibu-
ent head and neck positions. A long latency, progressive
lar, cervicogenic, and ischaemic dysfunction (Figure 5).
symptoms when held in the sustained test position of
However, it is also a test with multiple descriptions in
cervical extension and rotation, and a lack of habituation
manual medicine literature
. Terrett
described the test
103
13
with repeated testing are indicative of VBI and not of
with the patient seated, the arms outstretched, and the
cervicogenic dizziness or BPPV
. Oostendorp
reported
forearms supinated. The therapist moves the patient’s
45
46
a latency of 55 ± 18 seconds in these patients with posi-
head in an extension-rotation position with the patient’s
tive findings on variations of the De Kleyn-Nieuwenhuyse
eyes closed. Symptom reproduction and sinking of one
test (Figure 4). He also reported a recovery time of 120
hand into pronation implicates the vertebrobasilar sys-
± 40 seconds
. A positive test may include symptoms
tem
. Van der El
described this test with the forearms
46
13
84
of vertigo, nausea, diplopia, and dysphagia. Positive
pronated. Deviation of one of the arms with the head
signs may include nystagmus and dysarthria
(which
in mid-position indicates vestibular dysfunction. A lat-
1,13
may be noted by having the patient talk during the test
eral deviation of the contralateral arm in the opposite
hold). Pettman
noted horizontal nystagmus but the
direction of the cervical extension-rotation implicates
29
authors have noted vertical and rotary nystagmus in
the neck. Immediate arm motion suggests a somatosen-
symptomatic subjects.
sory dysfunction; a latency period indicates ischaemic
This test has been extensively studied with equivocal
dysfunction
. No data on reliability or validity were
84
results. Some authors reported significant decreases in
found. A test indicating ischaemic dysfunction suggests
blood flow
, whereas others reported no changes
.
the need for referral.
96,97
98,99
Support for this test becomes even more problematic with
case reports noting false negative results
and case
100,101
Vestibulo-Ocular Tests
series noting 75-100% false positive results
. Cote et
99,102
al
reported 0% sensitivity for detection of increased
These tests examine the vestibulo-ocular reflex (VOR)
103
impedance to blood flow, 0% positive predictive value,
circuit by inducing movements at an angular velocity
and 63-97% negative predictive value. This test (and the
cervical rotation test) is obviously a questionable screen-
ing procedure for VBI. Vidal
has recently questioned
104
its routine use, concluding that vertebral artery tests
are not clinically useful screening tools for VBI. Rather,
he suggested relying upon history suggestive of VBI,
medical history (especially when indicative of ischaemic
processes, such as coronary artery disease, transient isch-
aemic attacks, or cerebrovascular accidents) and other
relevant examination findings (e.g., during cranial nerve
and AROM tests). Due to the potential for harm with
this test and its poor psychometric properties, it should
not be done in patients with a positive medical history
or a history strongly indicative of VBI
. However, the
104
test may serve as a screening tool in patients not fitting
these categories. In those patients, a positive finding
with clear central neurological signs of nystagmus and
dysarthria on this test warrants referral.
Sustained Cervical Rotation Test
Sustained supine cervical rotation may also test for
VBI. Symptom behavior can be expected to be similar
Fig. 4:
Fig. 4:
F
De Kleyn-Nieuwenhuyse test
242 / The Journal of Manual & Manipulative Therapy, 2005
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