Concussion: Purely a brain injury or are there more pragmatic treatments?

Cervicogenic Dizziness, Cervical Vertigo

Concussion has been a hot topic in the last few years and continues to grow in awareness, diagnostic and treatment options in the field of medicine.  Rehabilitation professionals, such as physical therapists, play a vital role in recovery from this injury and can be argued to be the best healthcare provider to aid in a progressive, graded exposure to return to sport/play.  Treating patients recovering from this injury can be challenging but our field offers us the training and ability to address the multiple dimensions of symptoms; including the oculomotor, vestibular, cervical and central impairments.

Even though concussion can be considered physiologically a “brain injury”, there is a plethora of data correlating the mechanism of injury and impulsive forces to whiplash mechanism, such as seen in a car wreck (Elkin et al 2016, Alexander 2003, Hynes & Dickey 2006, Morin 2016).  So not only could impulsive forces in concussion involve the head, but the neck as well (Marshall 2015, Kennedy 2017).  This is not a new subject per say, but with the continued expression of “brain injury” and “central condition”; I want to express to my colleagues that symptoms of headache and dizziness could be generators of nocioception and/or alterered proprioception.  There have been some authors to go as far as suggesting concussion should be appropriately called the monikor craniocervical shaky syndrome (CCSS).

Instead of simply allowing the brain injury diagnosis sticker dampen the prognosis to allow healing to occur, it is recommended to consider the cervical spine a potential reason/cause for post-concussion persistent symptoms.  Considering dizziness after sport-related concussion is common and reported to be in 43-81% of cases (Alslaheen et al 2010, Duhaime et al 2012, Lau et al 2011), it is highly recommended to get the formal assessment, evidence and treatment for these patients.

Let’s move on together to aid in finding potential, pragmatic and VERY treatable region of the body.  It can be challenging to find which system is of particular importance in the driver of post-concussive symptoms, but if you think it is the cervical spine, we have the answers for you.


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 1st day includes the “Optimal Sequence Algorithm”, a multi-faceted physiotherapist diagnostic approach of Cervicogenic Dizziness, which includes ruling out central and peripheral disorders to rule in the cervical spine as driver of proprioceptive dysfunction.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

 

 

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Is Osteopathic Treatment effective on Cervicogenic Dizziness?

Cervicogenic Dizziness, Cervical Vertigo

While answering the question, “Is Osteopathic Treatment effective on Cervicogenic Dizziness”, I must preface to say I am not an osteopathic physician and do not practice in that theoretical construct.  However, for those readers who understand the mechanisms of manual therapy and history behind the field of Physical Therapy and Osteopathic medicine; I am sure you can appreciate the correlation of Osteopathic medicine and subset of Manual Therapy within the larger scope of practice in Physical Therapy.  Here is a synopsis if you haven’t delved into the history.  Understanding this correlation will allow the clinician to delve deeper into the literature of other professions in order to have a broader consideration of the effects of manual therapies on individuals suffering from Cervicogenic Dizziness and ultimately give your patients the most comprehensive treatment.

While inquiring PubMed for literature support, unfortunately the terminology of Cervicogenic Dizziness comes up empty.  Why?  Well, read a previous post for that.  Nonetheless, Cervical Vertigo brings me information from Hulse et al in 1975.  As expected, the thought process realms from disturbances of the upper cervical spine and the authors recommend manipulation as treatment of choice.

As the years go by, it is difficult to find literary works specifically for the benefit of Osteopathic treatment for Cervicogenic Dizziness.  However, we do have a some information provided by:

  • A case report by Kennedy in 2002
  • A case report by Shaffer in 2005
  • A case report by Fraix in 2009.
  • A case series by Berkowitz in 2009.
  • A case report by McCallister et al 2016 – of note, this was on a patient with severe TBI

Since these are in the lower levels of evidence, the main chunk of justification doesn’t start until when we delve into Fraix’s work in 2010.  A pilot study, here is Fraix’s conclusion

This study showed that OMT is generally well tolerated in patients with vertigo. It also demonstrated that it is feasible to recruit a population of patients with vertigo who can complete a course of OMT and collect data by using the DHI. A randomized control trial that examines the efficacy of OMT in patients with vertigo is warranted, given that OMT may be a reasonable treatment for vertigo and the functional impairment associated with it.

Of course this study has limitations, but I do like how it uses the Dizziness Handicap Inventory (DHI) as a functional outcome measure to show effectiveness of the intervention with a validated and reliable outcome measure.  See results in Figure 1 from the article below:

Fraix 2010

As far as I know, a follow-up RCT designed to compare Osteopathic Treatment to Vestibular Rehabilitation never made it to publication.  However, we do have some other evidence of the effects of osteopathic treatment in the last few years.

In 2013, Fraix and colleagues in a prospective clinical cohort study evaluated the effect of osteopathic manipulative treatment (OMT) for spinal somatic dysfunction in patients with dizziness lasting longer than 3 months.  Here is their conclusion:

Osteopathic manipulative treatment for spinal somatic dysfunction improved balance in patients with dizziness lasting at least 3 months.

Fraix 2013

In 2017, Papa and colleagues in a randomized control trial examined a group of 31 individuals with BPPV and again used DHI as outcome measure.  Here is their conclusion:

These findings suggest that OMT could be a useful approach to reduce imbalance symptoms and to improve the quality of life in patients suffering from dizziness

Papa 2017

In conclusion, the evidence is slowly, but starting to mount to give more credence to Osteopathic Treatment for Cervicogenic Dizziness.  I do not hesitantly justify this as simply another means of evidence denoting the benefit of manual therapy, which can be provided by trained physical therapists, for the treatment of Cervicogenic Dizziness / Cervical Vertigo.

The justification for our services and approaches are continuing to mount, for the sake of the patient, our referral sources, for us personally and for the 3rd party payers.  Anyone who has taken my courses knows evidence is a top priority and you will get the information you need to not only learn how to diagnose and treat Cervicogenic Dizziness, but the paper trail that puts more substance into our practice.


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

Would you harm a patient with manual therapy already diagnosed with concussion?

Cervicogenic Dizziness, Cervical Vertigo

The title of this blog is a loaded question, but generally speaking it entails the risk : benefit ratio and adverse events of performing manual therapy on a patient who has suffered a concussion.  In particular, we are speaking of someone who is suffering from post-concussive symptoms after mild traumatic brain injury (mTBI).  In this post, we will use mTBI synonymously with post-concussion symptoms. This patient is already in your office, you have determined some type of musculoskeletal generator for symptoms, most likely neck pain, dizziness and/or headache; so you proceed with what you have in your tool box.

Cervical spine involvement in mTBI is gaining more traction over the years. There have been countless case reports and case studies on the benefit of manual therapy for mTBI (to name a few–Gurnseley 2016, Burns 2015, Weltzer 2017).  In fact, Brolinson recommends using manual therapies alongside neuromotor/sensorimotor training for more effective  mTBI recovery than rest and exercises.  Also, we can’t forget the all important Schneider study from 2014 that found a significant number of athletes returned to sport in manual / vestibular group compared to control group.

Most recently, Quatman-Yates in 2016 found the following conclusion:

The results of this systematic review indicate that several physical rehabilitation options with minimal risk for negative outcomes are available for treating patients experiencing persistent post-mTBI symptoms. These options include: vestibular, manual, and progressive exercise interventions.

In general, the literature does guide us that manual therapies can be a safe and effective intervention to the cervical spine for mTBI.  In fact, if you break down adverse events in Cervicogenic Dizziness / Cervical Vertigo, you will not find the literature shying away from manual therapy either.  Even though no study has been conducted directly examining adverse events, it can be noted that the largest randomized control trial and long term outcomes to date by Reid and colleagues specifically state no adverse events in the group of eighty-six participants receiving manual therapy.

However, there is one study I want to bring to light.  It is from Dr. Greenman and his colleague, Dr. McPartland back in 1995 entitled, “Cranial findings and iatrogenesis from craniosacral manipulation in patients with traumatic brain injury“.  For those who do not know, Greenman was well known at Michigan State in Osteopathic Medicine and well cited in books and journals.  Even though the practice and treatment of craniosacral manipulation is beyond this blog and post, it is worth noting the findings of this brief review below:

Out of 55 cases, the authors describe 3 cases of adverse events of craniosacral therapy in patients with mTBI, including 2 requiring hospitalization.  They noted a 5% incidence rate and quoted the following, “craniosacral manipulation in a traumatic brain-injured patient can be useful and effective, but is not without risk”.

This number may not mean much to you—but we all hope as clinicians it is 0%—but it all depending on how you define iatrogenesis.  Nevertheless, I suggest you compare this number to Carnes’ 2010 study noting incidence estimate of proportions for minor or moderate transient adverse events after manual therapy was approximately 41% (CI 95% 17-68%) in the cohort studies and 22% (CI 95% 11.1-36.2%) in the RCTs; for major adverse events approximately 0.13%.

However, Sabel and Patini in 2018 in a pilot study examined safety of Osteopathic Manipulative Medicine in PostConcussion Symptom Management and elicited the following conclusion:

Osteopathic cranial manipulative medicine was considered a safe adjunctive treatment option to improve concussion-related symptoms and recovery.

In conclusion, I say there are minor adverse events to any intervention but we definitely want to have a treatment approach that minimizes risk while add benefit.  The type of technique, approach and handling skills can all be combined to making this formula turn out best for you and the patient.  In our Cervicogenic Dizziness Course, we teach a variety of techniques that add on what you already know and propel it towards maximal comfort and relief.  Come check us out near you.


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

How common is Cervicogenic Dizziness in Concussion?

Cervicogenic Dizziness, Cervical Vertigo

 

Concussion

Over 80% of concussions have been observed to recover within 7-10 days, but ~20% of sports-related concussions can take longer than this period of time to resolve.  Predictors and factors associated with a protracted recovery and reasons for post-concussive symptoms can be of many reasons but for the purpose of this post, we will delve into the cervical spine.

You can’t disagree that assessment of the cervical spine in post-concussion management and treatment is important.  However, the prevalence of cervical spine pathology in concussed patients is unknown.  Many authors express interest and promote the manual assessment of the cervical structures.  I recommend delving into the research by these authors: Leddy et al 2015, Gergen 2015, Scorza et al 2012Ellis et al 2015Craton et al 2017Cheever K et al 2016, Matsuszak et al 2016, Morin et al 2016Marshall et al 2015, Elkin et al 2016Putukian 2017, Lundblad 2017  , Schneider et al 2018 and Kosoy/Feinstein 2018.

Even though concussion research and awareness has spiked in the last few years, you can also go back to 1956 to read an article by Seletz in Calif Med Journal entitled, “Craniocerebral Injuries” (a free paper).  So, yes, this concept is not new.

However, if you’re looking for a newer model to adopt, I recommend reading Mark Lundblad’s work in 2017 paper in Int J Sport Phys Ther entitled, “A Conceptual Model for Physical Therapists Treating Athletes with Protracted Recovery Following a Concussion”.  He does mention that the first component to address (prior to neuromuscular control and strengthening) is cervical mobility and C1-2 should be of particular importance.

In regards to Cervicogenic Dizziness following Concussion, we don’t know the prevalence rates of Dizziness itself from the Cervical Spine but we do know most common symptoms are headaches, dizziness, fatigue and other range of cognitive deficits.  More research and scientific inquiry is on headaches vs dizziness from the cervical spine, but we can all agree even though we are looking at a proprioceptive vs nocioceptive alteration in input, that some of the actual structures at fault can be similar.

There will be tons more coming out in the concussion literature over the next few years to aid in prevalence rates themselves, but here are studies we present to our classes:

Just recently, Ellis et al 2018, in a retrospective cohort study, actually looked at Cervical Spine Dysfunction in Pediatric Sports Related Concussion.  Out of the 246 patients included in the study, 80 of them (32.5%) met the criteria for cervical spine dysfunction.  The authors conclude that cervical spine dysfunction can be a risk factor for delayed clinical recovery.

Kennedy et al 2017, in a retrospective chart review study, found that 32 of 45 (69.5%) of patients with persistent post-concussion symptoms, were found to have cervicogenic component.  The authors highlight the value of physiotherapy assessment and treatment of the cervical spine following a concussive injury.

Reneker et al 2018, in a cross-sectional study of athletes after a concussion, found 82.9% had cervical involvement and 26.8% presented with Cervicogenic Dizziness.

A classic, Schneider et al 2014, in a randomized controlled trial to treat concussion in adolescents, found 100% of patients in both treatment AND control group had cervical spine findings.  Moreover, 93.33% in treatment group had neck pain while 87.5% in control group had neck pain. Additionally, 86.33% had dizziness in treatment group and 82.75% had dizziness in control group.

Marshall et al 2015, albeit a review paper BUT also a case series, discusses the role of many theories causing post-concussive syndrome.   Pertinent to this post, the authors give credence to “a very treatable” cause of it—the cervical spine.  All of the cases demonstrate several different types of manual therapies to the cervical spine to aid in improving symptoms.

Growbaski et al 2017, in a retrospective cohort study, expressed that over 75% of the patients experienced symptoms consistent with peripheral vestibular disorder or cervicothoracic dysfunction, either in isolation or in various combinations, in their multimodal, impairment-based PT approach to treating post-concussion syndrome.

Browne GJ 2006 found that in the retrospective descriptive case series study of 125 children who injured their cervical spine while playing rugby football, 98% of them had neck pain (of course if injured neck), but out of these 125 children, 23% had a concussion.

Jensen et al 1990 found that 18 out of 19 (94.7%) patients with persistent post-concussive syndrome had upper cervical spine restrictions when compared to an uninjured control group. Their work concludes that it supports the hypothesis of a cervical mechanism causing post-traumatic headache and suggests that post-traumatic dizziness, visual disturbances and ear symptoms could be part of a cervical syndrome.

Treleaven et al 1994 demonstrated in 12 patients with post-concussive had upper cervical spine dysfunction compared to a normal control group.  This study examined headaches.

Going back even further, Mager et al 1989, noted a block of the upper cervical spine and of the cervicothoracic area was proved in 83.53% of patients who were hospitalized upon a head injury.

How common is Cervicogenic Dizziness after Concussion?

The values above are just several examples of prevalence rates of cervical component in head injury from concussion. Unfortunately, I don’t have specific values for you as most studies lump Cervical Dysfunction as criteria to treat musculoskeletal symptoms or Dizziness symptoms in peripheral disorders but don’t differentiate between the two.

However, we can at least appreciate that 1/4 of patients (25%) with concussion have Cervicogenic Dizziness following results of Jennifer Reneker’s work in 2015 BUT could be as high as 86% in Schneider’s work in 2014.  What do you see in the clinic?  Do you think the percentage is larger than what is presented in the research?

I hope this provides you some phenomenal information to take back to the clinic!  Overall, we can definitely rule out the cervical spine via a few tests and if you can’t rule it out, we do have some specific tests to aid in ruling in the condition.

Also—keep in mind, this data doesn’t include the plethora of information from the whiplash-associated disorder diagnoses either!  You will see a future post on this data so sign up for email alerts! If you’re seeing head injury patients, post-concussion syndrome, and even whiplash and do not address the cervical spine, I hope this post gives you credence to examine it further.


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 1st day includes the “Optimal Sequence Algorithm”, a multi-faceted physiotherapist approach to the assessment of Cervicogenic Dizziness, which includes the appropriate ruling-out process and cervical examination of the articular and non-articular systems. Also pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

5 reasons to take our Cervicogenic Dizziness Course

Cervicogenic Dizziness, Cervical Vertigo

1. Cervicogenic Dizziness is more prevalent than you think

Cervicogenic Dizziness, Cervical Vertigo

Nowadays, most people think of Cervicogenic Dizziness of arising after a concussion.  We can’t forget the higher percentage of patients suffering from Cervicogenic Dizziness after a whiplash, other mild traumatic brain injuries and patients with cervical arthritis.  If you see patients with neck pain, then they could have Cervicogenic Dizziness and you need this class!  Oh, and don’t forget the double entity of Cervicogenic Dizziness with your patients with BPPV.  Could this be the reason their symptoms come back??

2. Treatment for Cervicogenic Dizziness is MUCH more than just Mulligan Approach

Cervicogenic Dizziness, Cervical Vertigo

You can’t disregard the highest level of evidence in randomized controlled trials by Susan Reid and her colleagues in the successful treatment of Cervicogenic Dizziness.  We definitely go over and teach the powerful effects of this approach! However, if you read outside the physical therapy literature, you will find a copious amount of success in the treatment of Cervicogenic Dizziness from the Chiropractic works, Acupuncture Works,  ENTs, Audiologists,  and even from Medical Physicians.  With over 600 referenced articles in our course, we cover it all to give you the best of the best in all around treatments for Cervicogenic Dizziness.  If you want to know how to treat the upper cervical spine joints and fascial points manually and then with follow up exercises, all in one class, this is perfect for you!

3. You will be taught by both a Vestibular Specialist and a Manual Specialist

Cervicogenic Dizziness, Cervical Vertigo,

When my wife and I decided to put together our course, it was both exciting to bring our “two fields” together but challenging!  As a manual trained therapist, I have a different “lens” than she does, and as a vestibular therapist, she has a different “lens” than I do.  This is what makes our course both unique and personable!  You will not find this combination to bring you the best of the best in treatment of Cervicogenic Dizziness anywhere else.

4. Sensorimotor Training is the future of Physical Therapy

 

Cervicogenic Dizziness, Cervical Vertigo Courses

For anyone keeping up with trends and advanced in literary works, you will notice that much more data and evidence is arising for the benefit of Sensorimotor Training.  Considering the cause of Cervicogenic Dizziness is due to disruption in multiple systems with ultimate failure in the proprioceptive system, you cannot fully treat this condition without Sensorimotor Training.  Not only do we teach this approach after our manual therapies, but we have specific approaches and exercise programs for your patients suffering from Cervicogenic Dizziness.

5. Cervicogenic Dizziness is brushed on in your Vestibular and Manual Courses

Cervical Vertigo, Cervicogenic Dizziness

When my wife and I came together to write our > 300 page manuscript for our Cervicogenic Dizziness Course, we ultimately realized that Cervicogenic Dizziness was just brushed at the surface in both of our advanced training.  Therefore, we brought together a course that is perfect for a “vestibular” OR “manual” therapist that has the most detail and up to date information for any clinician.  If you “think” your patient has this condition or seeing a trend, you ultimately need to take the course to treat it most effectively.  Be the expert in both at your clinic!

$100 off 2018 courses ends July 6 for Richmond, VA and July 10 for Hawaii!  Sign up now to save money!


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 1st day includes the “Optimal Sequence Algorithm”, a multi-faceted physiotherapist approach to the assessment of Cervicogenic Dizziness, which includes the appropriate ruling-out process and cervical examination of the articular and non-articular systems. Also pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Cervical ROM Asymmetry in Cervicogenic Dizziness

Cervicogenic Dizziness, Cervical Vertigo

Flexion Rotation Test, AA, C1-2, Cervicogenic Dizziness, Cervical Vertigo

As much as I do not like the word asymmetrical in regards to musculoskeletal care for many reasons, we cannot neglect its role in the history of our profession.  Historically, clinicians would eye-ball range of motion and even use palpation to determine deficits side to side with resultant definitions and/or descriptions to the patient that could be the reason for his/her symptoms.  We all know the reliability and validity of these measures have their own downfalls and with advanced scientific scrutiny of our own tests, these methods are dying out.  However, there is one test that has been shown to be valid, reliable and useful in the differential diagnosis of certain conditions.  This test is the Flexion Rotation Test.

Back in 2004, Hall & Robinson were the first (to my knowledge) to study and cite the Flexion Rotation test in a comparative measurement study for Cervicogenic Headache.  This test has stood the test of time and continues to be highly valuable in studies examining the upper cervical spine.  I wrote a 3 part series on it over 8 years ago (Part 1, Part 2, Part 3) and still use it consistently to this day!  Even though the Flexion Rotation Test has been validated in Cervicogenic Headache and continues to be a major player in a battery of examination tools for Musculosketal dysfunction in Migraines, its role in diagnosing Cervicogenic Dizziness as a valid measure is lacking.

The purpose of the Flexion Rotation Test is to measure the mobility at the atlanto-axial (AA) joint, which of course is in the upper cervical spine complex.  It encompasses 50% of the rotation of the cervical spine and a major musculotendinous attachment point. Even though the neurophysiology of nocioception from the upper cervical spine to produce Cervicogenic Headaches is more common, there is a plethora of information on the proprioceptive neurophysiology from the upper cervical spine to produce Cervicogenic Dizziness.

Most recently, Quek et al 2013 sought out whether the upper cervical spine rotation ROM asymmetry is associated with postural stability.  The authors found Cervical Flexion-rotation ROM asymmetry group had greater postural sway and from a statistical analysis viewpoint, the study emphasizes the need to consider Cervical Flexion-rotation-ROM asymmetry as an independent predictor of standing balance, over and above the influence of neck pain intensity.  This is a powerful statement and considering we are dealing with altered orientation, dysequilibrum, and unsteadiness with Cervicogenic Dizziness; we can’t ignore this striking finding on correlating postural stability with AA mobility.

However, for MORE diagnostic power in evidence-based practice, we need MORE than just conjecture from basic science and relating range of motion to postural stability.

The clinical reasoning process to diagnose Cervicogenic Dizziness takes the basic science, add a screening process via the Optimal Sequence Algorithm , obtain the appropriate subjective and other objective testing measures—including the Flexion Rotation Test—and BAM…make the clinical diagnosis…doesn’t this count as validation?

Honestly this is what we currently have in regards to using the Flexion Rotation Test for Cervicogenic Dizziness.  We don’t have a true validation study as we do with Cervicogenic Headaches, but we do have some more oomph from the ivory towers to help make our decision.  To assist with our argument, we have case reports (Gargano et al 2012), case series (Escaloni et al 2018Jung et al 2017) Delphi Study (Reneker et al 2015), case control study (Morgan CD et al 2015), reviews (Cheever K et al 2016) and position statement (Harmon et al 2013).  These literary works all discuss and/or use the Flexion Rotation Test for Cervicogenic Dizziness.

One thing I want to point across is the lack of validation of a test does not mean you can’t make inferences.  With basic science input from C0-3 and several studies demonstrating the abnormal findings of C1-2 via the Flexion Rotation Test relating to patients with dizziness, we can’t ignore this excellent test.  Use it but use it with strong clinical reasoning for your patients with dizziness to determine how much could be musculoskeletal in nature.


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 1st day includes the “Optimal Sequence Algorithm”, a multi-faceted physiotherapist approach to the assessment of Cervicogenic Dizziness, which includes the appropriate ruling-out process and cervical examination of the articular and non-articular systems. 

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Sensorimotor Impairment Treatment in Concussion and Whiplash Patients

Cervicogenic Dizziness, Cervical Vertigo

It is now well know the correlation between symptoms and physiological effects that are sustained following patients who suffered from concussion and whiplash.  Even though there are still apparent differences clinically, we can now feel comfortable to lump these two conditions together.  It may surprise some readers — but in this article — and most likely in the medical literature in the future — we will collectively call the injury a mild traumatic brain injury (mTBI).

Galea and colleagues just came out with a Meta-Analysis in 2018 to determine whether persistence of sensorimotor or physiological impairment exists between 4 weeks to 6 months post injury.  More than likely the clinicians reading this article will see a patient suffering from symptoms > 10 days following the injury for definition  of post-mTBI symptoms, but could be between 4-12 weeks so your patient fits in nicely in the objective.  More than likely we are seeing them for dizziness, headaches, neck pain, difficulty concentrating, etc.

For those interested in reading the entire analysis, feel free to reach out to me for article, but for blog purposes; here is the conclusion:

Findings demonstrate that persistence of sensorimotor and physiological changes beyond expected recovery times following subacute mTBI in an adult population is possible. These findings have implications for post-injury assessment and management.

Big points I want to you to get out of this conclusion.

Firstly, the “is possible” statement from first glance isn’t conclusive at all—but for a meta-analysis—I will take it!

Secondly, and reason we aim for to read and perform research, is this statement, “these findings have implications for post-injury assessment and management“.

The assessment and management of this very complicated and the challenging condition of mTBI is beyond what can be written in words.  In fact, my wife and I teach 16 HOURS worth of updated and modern content to make you more confident in treating someone suffering from mTBI who has Cervicogenic Dizziness / Cervical Vertigo.  This doesn’t even include the science and application of treating the other symptoms!

We do know that the presentation of a patient who could have Cervicogenic Dizziness / Cervical Vertigo is much more than someone who has suffered a recent mTBI; but this Meta-Analysis has huge implications for our instructional content and approach.  In fact, a large percentage of our course is dedicated to the assessment and management of Sensorimotor changes.

Doesn’t this last bolded statement correlate nicely with the latest highest-level evidence from Galea et al that was quoted above?

If you’re looking to maximize your patient’s outcomes—check out a course near you!


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

Is it Cervical Vertigo or Cervicogenic Dizziness? A Clarification

Cervicogenic Dizziness, Cervical Vertigo
Courtesy: http://www.itprotoday.com

Any clinician working in the neuromusculoskeletal field knows we have a big problem in describing conditions that we diagnosis and treat.  You get 10 PTs to examine a patient and you may get 10 different explanations.  A colleague’s work has even just eliminated all abbreviations across all of their clinics as we can’t get that right either!

Additionally, there has always been the multi-term description of a “joint problem”—somatic lesion, derangement, dysfunction, hypo mobile joint, hyper mobile joint, etc etc.  The trend is even getting less specific with conditions that have historically carried a diagnostic term.  Subacromial impingement is now being called anterior shoulder pain and patellofemoral pain syndrome is now being called anterior knee pain.

One of the main reasons for this discrepancy is that we have a challenging time correlating the actual source of nocioception from a clinical exam, and can be even less accurate with imaging exam for the above two conditions.  Even more, the purpose of a diagnosis is to lead to a sound treatment plan, but this depends on multiple variables.  Providing a clarification for our findings is challenging.

In the dizziness world, the subjective and variable explanation of symptoms makes the clarification of terminology even more challenging.

The current medical definitions of vertigo, dizziness, and imbalance are based on the recommendations made by the classification committee of the International Bárány Society for Neuro-Otology.

Vertigo is the sensation of self-motion when no self-motion is occurring; dizziness is the sensation of disturbed or impaired spatial orientation without a false or distorted sense of motion; and imbalance or unsteadiness is the feeling of being unstable while sitting, standing, or walking without a particular directional preference.

Additionally, dizziness may be described as feeling dizzy, lightheaded, giddy, faint, spacey, off-balance, rocky, spinning, or swaying (Newman-Toker DE & Edlow JA 2015).  Aren’t these descriptions all over the board?!

The definition of Cervicogenic Dizziness / Cervical Vertigo is even more muddy.  Here is a sample of dizziness descriptions from leading authors, alongside correlating them with neck positions/movements.  This is a small collection from my 300 page book (provided with course registration):

Non-rotary dizziness, imbalance, unsteadiness (Reid 2008/2012/2014/2015)

Vague sense of impaired orientation or disequilibrium (Al Saif 2011)

Non-specific sensation of altered orientation in space and disequilibrium (Furman/Cass 1996, Wrisley 2000)

For the most part, dizziness means different things to different people.

One thing I want to point out is that the description and definition of Cervicogenic Dizziness does not involve vertigo—which is definied as a “sense of spinning, surroundings seem to whirl such as feeling that you are dizzily turning about you”.  This is typically associated with BPPV (hence the “V”).  

In the literature on this topic, you may find  the phrases, “Cervical Vertigo (CV) , Cervicogenic Dizziness,  or Cervicogenic Vertigo” as you search across multiple discipline journals.  Considering vertigo is not a typical description or definition associated with dizziness associated with the cervical spine, I suggest abandoning the phrases, “Cervical Vertigo (CV) and Cervicogenic Vertigo”.

You will still find these other terms in overseas texts and articles, so do not abandon it completely in chasing down research, but we do need to continue a trend towards being consistent across our professions.  Therefore…

Let’s just stick with good ol’ Cervicogenic Dizziness.


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Finally. After 17 years, it’s here.

Cervicogenic Dizziness, Cervical Vertigo

Through my professional life, I have always heard it takes 17 years for evidence to be implemented into clinical practice.  With technological advancements in social media and search capabilities to gain knowledge from literary papers, I feel this number has to be much less nowadays.

While teaching this past weekend, I brought this up.  One of the participants has been treating for 41 years, yes, 41 years!  She quickly reminisced of how different things were back then to share with the class.  Of course obtaining more knowledge and reading papers isn’t a quite Google search and follow someone popular on social media platforms.  During those years you actually had to go and search for what you’re looking for professionally.  Makes us feel lazy now doesn’t it…

The timing of 17 years is coincidental in the context of Diagnosing Cervicogenic Dizziness.  Anyone who has had any interest in this topic has read Diane Wrisley’s work: Cervicogenic Dizziness – a Review of Diagnosis and Treatment in our own JOSPT from the year 2000.  It is well cited throughout other profession’s works and continues to be almost a “gold standard” go-to when talking about this topic.  You can find it easily online here.

17 years later, in 2017, Alexander Reiley and colleagues right down the road from me at Duke University came out with an updated paper entitled, “How to diagnose Cervicogenic Dizziness”.  Within the journal Archives of Physiotherapy, this is an excellent article and has some updated information on the topic.  As an open access article, you can also access it easily online here.

Some of you may think, Harrison—why are you sharing these articles as this is what you and your wife teach during the entire first day on your course circuit!  The purpose of our course is to get this information OUT THERE—to propel our profession forward as the go-to providers to treat Cervicogenic Dizziness / Cervical Vertigo.  We have the background training, the openness in our diagnostic and treatment approaches, the integration of vestibular and manual therapies specialities to change lives.

Also—as I said this past weekend to class participants—we have known about Mark Laslett’s SIJ cluster for 10 yrs to diagnose SIJ dysfunction—but we continue to search how to best to TREAT it.

Well—you can always read in papers how to diagnose something, but we do offer our solutions to TREAT it on our second day.  🙂

Coincidence of 17 years with update in this diagnostic process system in our professional journals…maybe so.


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

 

Should you recommend surgery for Cervicogenic Dizziness?

Cervicogenic Dizziness, Cervical Vertigo
Image result for neck surgery
https://upload.wikimedia.org/wikipedia/commons/thumb/4/4e/ACDF_surgery_english.png/350px-ACDF_surgery_english.png

It is well established that conservative treatment should be the primary choice of intervention for non-specific neck pain as the benefit of surgery over conservative care is not clearly demonstrated.  For rehabilitation professionals, the use of exercise therapy and/or manual therapy is obviously the most appropriate decision and should always be utilized prior to most invasive, risky procedures.

This is echoed in the Cervicogenic Dizziness / Cervical Vertigo literature as well.  We have three systematic reviews demonstrating the benefit of non-surgical and non-pharmacological interventions, specifically manual therapy, for these patients.  The high level of evidence all originated in 2005, then again in 2011 and even though just showing effectiveness of acupuncture, endorsed recently in 2017.  Although only three SRs, I think this is very positive considering a condition not well studied and continues to carry the burden of controversy.

Even with substantial evidence showing the effectiveness of conservative care, specifically manual therapies, for Cervicogenic Dizziness / Cervical Vertigo, there are still several citations illustrating success following surgery.

Here is a glimpse of the literature with accompanying conclusion:

Yang Y et al 2007
“Percutaneous laser disc decompression can decrease intradiscal pressure, increase local temperature and remove the spasm of the vertebral artery while providing a remarkable therapeutic effect for the treatment of cervical vertigo.”

 Ren L et al 2014

“Excellent outcome in 18 out of 35 patients who underwent percutaneous laser disk        decompression”
Li J et al 2014

“Good results following more extensive cervical surgery”

Park J et al 2014

“Patient vertigo disappeared after surgical decompression of transverse foramen of C1”

Liu XM et al 2017

“ACDF provided a good resolution of cervical vertigo in a retrospective study of 116 patients”
Yin HD et al 2017
“Radiofrequency ablation nucleoplasty improves the blood flow in the narrow-side vertebral artery in 27 patients diagnosed with cervical vertigo and illustrates the therapeutic effect on cervical vertigo. Radiofrequency intradiscal nucleoplasty can be used as a minimally invasive procedure for treating cervical vertigo”

You can see a trend in the just the last few years indicating success of vertigo/dizziness after surgical procedures.  As an evidence-informed practitioner or even a vestibular specialist who isn’t trained in treating the neck, and recognizes lack of consistent relief in your patient, you may seek out this research and consider referring on to a surgeon.  Before you do so, let’s dive into the most recent article with surgical success to jack into a clinical reasoning discussion.


Patients/Methods: Of 145 patients with cervical spondylosis and dizziness, 116 underwent anterior cervical decompression and fusion and 29 underwent conservative treatment. All were followed up for one year. The primary outcomes were measures of the intensity and frequency of dizziness. Secondary outcomes were changes in the modified Japanese Orthopaedic Association (mJOA) score and a visual analogue scale score for neck pain

Results: There were significantly lower scores for the intensity and frequency of dizziness in the surgical group compared with the conservative group at different time points during the one-year follow-up period (p = 0.001). There was a significant improvement in mJOA scores in the surgical group.

Conclusion: This study indicates that anterior cervical surgery can relieve dizziness in patients with cervical spondylosis and that dizziness is an accompanying manifestation of cervical spondylosis.


Out of China, Dr. B Peng and his colleagues recently had this article published in the Bone & Joint Journal (not the best journal but higher impact factor than JOSPT). This is a level 2 multi center prospective cohort study—not bad when considering level of evidence as we have very few studies higher up on the chain and most involve the same name of Susan Reid & her colleagues from the land of Australia.

From initial glimpse of methodology, results and conclusion (you know we all typically look at the abstract…), my thoughts are that if my patient has arthritis and dizziness, then if they have surgery, they will have less intensity and frequency of dizziness compared to conservative route.

The first thing I did was to look at what type of conservative treatment was performed.  Here is the description:

Conservative treatment included physiotherapy, intermittent cervical immobilization with a collar, nonsteroidal anti-inflammatory drugs and rest.

This doesn’t tell us much what kind of physiotherapy was performed (stabilization exercises, heat/ice, e-stim, massage, squeezes for the shoulder blade squeezes with theraband, neck ROM—hell we don’t know!).  We don’t know what was meant by rest, or what was meant by intermittent immobilization of the spine (does anyone do this nowadays anyway?).  For all purposes, it could be the Physio Blend buffet style…but doubtful.

The second thing I did was look at the type of patients that were recruited.

Between March 2014 and March 2015, 157 patients with cervical spondylotic radiculopathy and/or myelopathy from three spinal centres (General Hospital of Armed Police Force, Beijing; 304th Hospital, Beijing; Changzheng Hospital, Shanghai) were enrolled in the study.

Additionally, the patients had failed conservative treatment (3 months of treatment!) prior to potentially having surgery—-34 of the 157 patients declined surgery—but continued with conservative treatment—and this was the group that surgery was compared to!  I’m sure the patients who continued with PT after 3 months were stoked to continue more of the same cervical immobilization, rest, NSAIDs and general physiotherapy….

The third thing I did—write this blog.

Big key points:

This is not a bash against the article—I thought it was well written and authors were open to the limitations in the conclusions.  They even stated the patients selected for study were for myelopathy/radiculopathy and not dizziness!  But, knowing the time and effort that goes into reading research in the profession—the title and abstract could be misleading to the consumer and I felt this blog would be beneficial to my rehabilitation colleagues.

Just like any condition we treat, this paper exemplifies a double entity.  Yes, the patients had improvement in dizziness following the procedure, but I would really say these patients had success of cervical pain due to cervical spondylotic radiculopathy and/or myelopathy, NOT cervicogenic dizziness.

This paper also exemplifies the notion that dizziness can arise from the neck, and can improve with intervention!  So yes, still can be controversial in the medical eyes, but this group sought out improvement in dizziness following the procedure indicating a cause/effect relationship.

Further, if you’re a vestibular therapist seeing patients you think that symptoms could be arising from the cervical spine, don’t just pass on to your orthopedic mate in the clinic.  Get some training, some real training.  We can help you with that.

You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts