VERTEBRAL ARTERY TEST (VAT)

Published in the AMT Journal "In Good Hands", September 2008
© AMT 2008, © Colin Rossie 2008. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.

Over the years I have heard all sorts of stories about the efficacy and safety of the VAT. I've researched to find out all I can about it; some research indicates it's completely useless in indicating vertebral artery compromise. Nonetheless, I would do it each time before working on the cervical spine. In the absence of any alternative, I believe it's better to be safe than sorry.

I know at least two versions of it:

One is the cervical quadrant test, which involves, while the client is supine, bringing the head and neck into extension and side-flexion, and holding for 30 seconds,

The other is the deKleyn Nieuwenhuyse Test, which is similar: with the client supine, the practitioner passively brings the client's head into extension, then passively rotates the cervical spine instead of side-flexing it. This test is performed bilaterally.

There is also Hautant's Test, which tests for the same but in the seated position, as well as Barre's Test, which is the same thing but done in the standing position.

If dizziness, nausea, dipoplia or other vision disturbance, disorientation, ataxia, impairment of trigeminal sensation or nystagmus are provoked by any of these tests then your client is recording a positive: testing should cease immediately and they should be referred to their primary care physician.

I would recommend all practitioners familiarize themself with all of the above tests. These can all be found in a suitable examination and assessment text.(1,2)

After problems arising from it being done by a student in a college clinic, it is no longer taught at some massage training colleges. I think this attitude is a huge loss to massage or bodywork education. Perhaps the problem with the supine VAT arose through lack of supervision: perhaps it was over-enthusiasm, the student possibly applying, however slight, an over-pressure in the extension, the lateral flexion, or the rotation component of the testing. I've always performed these tests gently as passive tests, with no over pressure, and have never had a problem with a client, other than the occasional positive.

In my clinical experience, there has always been a higher incidence of clients recording a positive response to these tests than actually having vascular compromise. Often the problem is a middle ear/ balance issue. In any one year, I'll have at least ten clients test positive to the VAT. I always suggest they go to their doctor for further testing.

Half do, half don't. I rigourously follow up and encourage them to. In most cases it turns out that I am just being overly cautious - in the last ten years, most of those who have seen their doctors have had nothing wrong. A few have recorded high cholesterol levels; some have had vestibular compromise; one, a male amateur cricketer, 32 years old at the time, who otherwise seemed perfectly healthy, had a berry aneurysm; another, a yoga-practicing vegetarian in her late 40s, had an atheroma in her left carotid artery; and yet another had over the top hypertension. A client last year had a condition known as Cerebral Arterio Venous Malformation and after seeing her GP had immediate surgery with Dr Charlie Teo. None of these people would be walking on the planet today had they not been made aware of a possible problem via the VAT.

All those clients were thankful that such a thing was picked up. Several local doctors initially found it amusing that a massage therapist would write them a letter explaining their observations and refer clients to them. They now have a different attitude to professional massage therapy and bodywork. Though I tend to err excessively on the side of caution, these doctors are no longer surprised by such referrals and rather than dismiss them out of hand will consider my concerns, test their patient and respond to my concerns.

Now, a not so happy story. As a gift to her PA, one of my regular clients sent her to see me. The PA was in her late 20’s, classic “A” type, well organized, very bright, a fit, gym junkie. Her major complaint was “sore neck & shoulders”. The first thing I did in the session was a VAT. She came up positive so we calmly discussed what a positive result could mean and that before we could proceed with any work that I would need clearance from her doctor. I didn't work on her, and would not do so until I had the all clear. She didn’t return, and answered my queries about whether she had seen to it yet with a casual “I’ll get around to it one day”. Eight months later she died of a cerebral stroke while out running at 6 a.m.

1) Magee, D. J. “Orthopedic Physical Assessment” Saunders
2) Petty N.J. & Moore A.P. “Neuromusculoskeletal Examination & Assessment” Churchill Livingstone