General Questions

1. Describe the anatomy of the vertebral artery.

- The vertebral artery arises from the upper aspect of the first part of the subclavian artery, runs
vertically upwards to enter the foramen transversarium of the transverse process of C6.

- Then it passes through the foramen transversaria of the upper six cervical vertebrae. After
emerging from the foramen transversarium of C1, it winds backwards around the lateral mass of
the atlas and enters the cranial cavity through foramen magnum.

- In the cranial cavity, it unites with the vertebral artery of the opposite side at the lower border of
the pons to form the basilar artery.

- The vertebral artery is one of the principal arteries which supplies the brain. It is the first and
largest branch of the first part of the subclavian artery

2. What are the signs and symptoms of vertebral artery insufficiency?

a. Headache

b. Neck pain

c. Shorten of breath

d. Facial symptoms, tingling

e. Visual disturbance

f. Speech disturbance
 g. Balance problem

h. Paralysis

i. Weakness muscles in arms and legs

j. Issue of their thinking ability

- Lot of people have vertebral artery issue, has predisposition could be a congenital problem

3. What should be included in your history taking to determine if there is a compromise of the
vertebral artery/

- Ask about any Headache issue, facial, speech disturbance, problem of mental acuity
- Question familial history of Stroke, Cardiovascular disease (CV) Disease, hypertension, smoking,
cervical spondylosis, bleeding disorders, medications (anti-coagulant and arthritides)

4. What is the incidence of vertebral artery stroke from chiropractic manipulation?

- Depend on what you read, some is 1 out 3 million manipulations, some 1out of 20,000

5. It is possible that the true incidence of vertebral artery stroke is over-reported or under-
reported? Explain your answer.

- Under-reported
- But always try to be careful and pay attention

6. What does CPirls stand for and how is it used? Do you this is a useful recording tool?

- Chiropractic Patient Incident Reporting and learning system - Strong tool for the documentation of
incident, data collected is used as training tools to build better outcomes.
-
7. People who suffer vertebral artery insufficiency are young healthy adults between the ages of 3-
45 years, more females than males having an uneventful medical history: True or False?

- True

8. What are the risk factors of VBAI?

- Mechanical trauma, high blood pressure, infection, Cardio Vascular disease (hypertension,
hyperlipidaemia, diabetes), history of smoking, age over 55years

9. What is the standard recommendation for cervical spine adjustments/manipulation for rotation?
Why is this standard in place?

- No more than 30 degrees, short sharp thrust, little to no rotation

10. What are the different types of vertebral artery injury?

- Dissection and blunt trauma - Mechanical injury

11. Describe the tests for the vertebral artery? Are they valid?

- Hortons test, - arms out close eye, one hand pronate (can be in sitting position)
- Under bergers – upright, do some stepping, close eye, if there is swag in on direction
- Maximum Cervical compression (Declines) – extension, rotation (maximum), lateral flexion
- Provocation – Consistent nystagmus, Changes in sensation to face, dizziness

12. What is your recommended physical examination procedure to confirm vertebral artery testing?

- Take a good patient history, Trauma, Cardiovascular problems / assessment

13. Describe the reason for ‘informed consent’ with VBAI.

- Medical Legal requirement. Need to inform of risks and benefits and alternatives for treatmen

14. What is the mechanism for injury for ‘Whiplash’?

- Hyperflexion / hyperextension injury due to the sudden displacement of the head to the trunk
from abrupt acceleration and deceleration.

15. What structures/tissues are injured in a hyperextension whiplash injury?

- Over stretch of the anterior structures of the neck and compression of the posterior structures.
Tends to focus around C5-C6, occiput may strike shoulders.
- Stretching and tearing of the anterior longitudinal ligament, SCM, Scalenes, Longus Colli
- Marginal fracture of the Vertebral body
- Anterior disc protrusion
 - Compression of the vertebral artery of C1
- Compression of the C2 dorsal root ganglion
- Retropharyngeal Haematoma
- Spinous or posterior arch of C1 fractures
- Posterior subluxation of C4,5
- Compression of the spinal cord
- Dislocation of C3

16. What structures/tissues are injured in a hyperflexion whiplash injury?

- Overstretch of the posterior structures with compression to the anterior structures. Tends to
involve the occiput region
- Usually less severe
- Overstretch of posterior structures with compression anterior to the spine
- Tends to involve suboccipital region
- Lateral flexion (Sidelash)
- Mandatory headrests
- Females more affected

17. What are the different degrees of injury for a whiplash patient?
1st degree:

- myofascial strain. Pain develops 12-48Hrs, heals rapidly should be symptom free within 6mths.

2nd degree:

- moderate -severe injury, Pain develops within 12hrs of injury, some disability, usually normal after
6-24mths

3rd degree:

- Severe, Pain immediate or within 2hrs increasing in 24-48hrs. ALL tearing and separation of the
vertebra. 3-12% still have dysfunction after 2-3 yrs.

4th degree:

- Fracture / dislocation. May be permanently disabled.

18. What are the different phases with treatment?
Phase 1:

- Pain reduction, treatment of inflammation and muscle spasm. Goal = no pain at rest. 4-21 days

Phase 2:

- recovery of functional movement. Goal = capacity to perform unstressed daily activities.

- 22-45 Days

Phase 3:

- Restore normal movement patterns along with conditioning of normal strength and function.
- Goal = capacity to perform normal activities under some constraints and conditions. 46-180 Days

Phase 4:

- Return Pt to full active lifestyle and help to prevent future episodes.

- Goal = recovery to full, normal and uncontrolled activities, release from active care. > 6mths –

recovery prognosis.

19. According to the ‘code of conduct’ (link found in week 5), what are the 14 factors that reflect
‘good practice’
1) Recognising and working within the chiropractors competence and scope of practice

2) Maintaining adequate skills and knowledge to provide safe and effective care, partake in
continual education and have the ability to recognise lapses in knowledge and refer to other
health professionals when required.

3) Promote patient centred care, empower patients to take an interest in and responsibility for
their health and provide assistance and guidance when required.

4) Maintain adequate records

5) Consider the balance between benefit and harm making clinical decisions.

6) Communicate effectively with Patients

7) Provide treatment/care that is evidence based, supported by the best available evidence
and not be influenced by financial gain.

8) Ensure services offered are provided with best possible skill, care and competence.

9) Take the best possible steps to alleviate a patient’s symptoms and distress.
 10) Support a patient’s right and wishes to seek a second opinion.

11) Take advice and seek consultation from colleagues when appropriate.

12) Make responsible and effective use of the resources available to chiropractors.

13) Ensure the chiropractors personal views do not adversely affect the care of the patient.

14) Reflect and evaluate the actions, decisions and practice of providing good care.

Refer to the PDF on the ‘Code of Conduct’ from the Chiropractic Board of Australia and answer the
following questions. Refer to ‘working with patients’ section 8

True or False

1. Good practice involves understanding and applying the key principles of risk minimisation and
management in practice.

- True

2. It is not important for ALL chiropractors to report adverse events.

- False

3. The National Law requires that chiropractors (and all of the regulated health professions) keep
their knowledge and skills up to date through CPD to ensure that chiropractors can continue to
work within their competence and scope of practice.

- True