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Can Vestibular Rehabilitation Improve Dizziness After A Concussion?

Cervicogenic Dizziness, Cervical Vertigo

Reidar Lystad and colleagues in 2011 published a critical systematic review entitled, “Manual Therapy with and without Vestibular Rehabilitation for Cervicogenic Dizziness: A Systematic Review”.  I say it is critical because of the following conclusion,

There is moderate evidence to support the use of manual therapy, in particular spinal mobilisation and manipulation, for cervicogenic dizziness. The evidence for combining manual therapy and vestibular rehabilitation in the management of cervicogenic dizziness is lacking. Further research to elucidate potential synergistic effects of manual therapy and vestibular rehabilitation is strongly recommended.

I highlighted a particular important outcome of the systematic review in bold above.  Basically, just 7 years ago (at time of writing this blog), we do not have the highest level of evidence telling us we should perform vestibular rehabilitation on patients diagnosed with Cervicogenic Dizziness!

In the era of evidence-based practice, we know this is just one leg to Sackett’s stool; but can’t deny the power of a systematic review!

One thing we point out in our Cervicogenic Dizziness Course is if you delve into this review, you will note that there are no studies that indicate use of Vestibular Rehabilitation in Cervicogenic Dizziness, therefore, of course the evidence is lacking!

Cervicogenic Dizziness, Cervical Vertigo
http://www.iccseminars.com

Over the years as medicine and practice knowledge grew, we have been able to add onto this statement with a Randomized Control Trial, a Retrospective Chart Review and an Exploratory Study  Even though only three articles, this is better than none back in 2011!  This was exposed in a recent article in 2018 entitled, “Vestibular Rehabilitation Therapy Improves Perceived Disability Associated with Dizziness Post-Concussion” to express there is level 2 and level 3 evidence supporting the use of vestibular rehabilitation to treat patients suffering from dizziness post-concussion.

I would also add, even though not specific to post-concussion, Jaroshevskyi’s work in 2017 finding the following conclusion:

The multimodal approach using manual therapy in combination with acupuncture and vestibular rehabilitation showed the maximum therapeutic effect on elimination of musculo-tonic disorders, reduction of a pain syndrome with a complete regression of vertigo and postural instability.

The last study is one I want to bring to light and expose that ultimately, to achieve maximal therapeutic benefit, we CAN’T limit ourselves to just performing manual therapies OR vestibular rehabilitation for a complex disorder such as Post-Concussion Dizziness, Cervical Vertigo or Cervicogenic Dizziness.

We should, and need to, continue to blend the two specialities so patients can achieve the best of the best treatments to maximize recovery, decrease symptoms, and return to sport.

This is why Drs. Vaughan created the Physio Blend for treatment of Cervicogenic Dizziness — it is the most researched and skillful approach to tailor to these complex cases.

If you are a Vestibular Therapist wanting to learn specific manual therapies or a Manual Therapist wanting to learn vestibular rehabilitation for your patients, this is the course 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 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

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2 manual techniques are better than 1 for Cervicogenic Dizziness

Cervicogenic Dizziness, Cervical Vertigo

A 2019 randomized control trial entitled, “Combined use of cervical headache snag and cervical snag half rotation techniques in the treatment of cervicogenic headache” by Mohamed et al has caught my attention.   I enjoyed reading this study due to not just having 2 randomly assigned groups, but it had a 3rd group ===> one of which combined techniques from the first 2 groups to see if patients get better results vs just determining if a single procedure provides pain relief and functional improvements.

After 3 sessions per week for a month, here is conclusion:

Results of the study showed a significant improvement in post-treatment scores of all measured variables within groups and among the groups with the combined groups showing the greatest improvement.

Table from Muhammed et al 2019
Post-treatment NDI was significantly lower in Group C compared to the other two groups (p<0.001) and was comparable in groups A and B (p=1.000). The percentage drop of NDI was significantly higher in Group C compared to the other two groups (p<0.874), but the magnitude of NDI drop was comparable between Groups A and B (p=1.000, Table 2).
Table from Muhammed et al 2019
HIT-6 was comparable in the three groups (p=0.936), and decreased significantly after treatment in all the three groups (p<0.001 for all comparisons). After treatment, it became significantly lower in group C compared to the other two groups (p<0.001) and was comparable in groups A and B (p=1.000). The percentage decrease of HIT-6 was significantly higher in group C compared to the other two groups (p<0.001), while it was comparable between Groups A and B (p=1.000).

There you go — performing 2 procedures (very specific procedures in this case) yields better results than a single procedure – especially in Headache Impact Test and Neck Disability Index.

You may ask how Cervicogenic Headache (as was diagnosis in this case) relates to Cervicogenic Dizziness in this post — we know there are overlapping pathophysiology mechanisms associated with the afferent input dysfunctional theory but also specifically for this study, ALL the patients had a trigger of dizziness with onset of headache and cervical extension — a prime movement associated with diagnosis of Cervicogenic Dizziness.

Cervicogenic Dizziness, Cervical Vertigo,

Generally speaking, combined procedures are what most clinicians perform in the clinic.  This is due to multiple impairments (such as joint restriction, heightened muscle tone, motor control deficits, etc) are typically found in a patient suffering from cervical pain.  Randomized trials have to limit variables in order to make a correlation hypothesis so as clinicians “in the trenches” who are looking for the best approaches to manage our patients, reviewing the results of randomized trials have limitations.

Even though most aged clinicians in our industry are tired of the “comparison” model of different manual therapy techniques, I like how this study combined techniques for a 3rd group — one of which I personally see better improvements in the clinic vs a single procedure.  I’m sure all treating clinicians agree.

Interesting enough to the clinician, the Dizziness Handicap Inventory did not show a significant improvement in the combined groups compared to single procedures.  See table below.

Table from Muhammed et al 2019
Before treatment, DHI was comparable in the three groups (p=0.501) and decreased significantly after treatment in the three groups (p<0.001 for all comparisons). After treatment, it became significantly lower in group B compared to group A (p=0.018). It was comparable between groups B and C (p=0.869) and between groups A and C (p=0.269). The percentage decrease of DHI was significantly higher in group B compared to group A (p=0.035). It was comparable between groups B and C (p=0.720) and between groups A and C

This finding does not surprise me at all.  In my opinion, the pathophysiology behind Cervicogenic Dizziness is more complex than Cervicogenic Headache with more “moving parts”.  It may well explain that to improve Dizziness related function to highest degree, the clinician may need to combine joint procedures, soft tissue procedures (aimed at high muscle spindle locations) and sensorimotor training.

Cervicogenic Dizziness, Cervical Vertigo

This is how we approach Cervicogenic Dizziness, coming solely as a single entity but also combined entity (i.e. associated with BPPV, mTBI, concussion, whiplash, peripheral hypofunction, etc).  We do this through our Physio Blend — a solid mix of combined approaches with research from the Physical Therapy (Manual and Vestibular Rehabilitation) Chiropractic, Acupuncture, and Osteopathic Medicine.  We find that this is the ultimate combined approach for this more complex and “moving parts” diagnosis. 


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 

Can you get a concussion from impact to the chest?

Typically when someone thinks of a concussion, a picture below comes to mind.

But, we also know sport-related concussion is just one type of injury that is associated with the diagnosis of concussion, or mTBI.  Prior to the recent build-up of information and data on concussion in sport over the last several years, we would treat similar symptoms in patients presenting with whiplash-associated disorders.

So, for those us treating whiplash, this type of image usually comes to mind.

One impact approach that typically doesn’t come to mind, but could potentially be more prevalent (although may require twice the rotational velocity) in contact sports (especially with changes in tackling rules) is the biomechanical response to the cervical spine from primary impact to the chest.

Potentially a picture like the one below can come to mind.

Instead of just helmet-to-helmet collisions, we can’t forget impulsive force transmitted to the head from a direct blow somewhere else.  This is in the definition from the 2012 consensus statement and considering the acceleration strain placed on the head and neck with this type of impact, we don’t want to forget this mechanism and potentially rehabilitation methods with this type of contact.

A recent study by Jadischke R et al in 2018 examined the biomechanical response and strain of the upper cervical spine and brainstem from chest impact in their study entitled, “Concussion with primary impact to the chest and the potential role of neck tension”.

Even though chest impact collisions causing concussion place lower stress on the neck, the authors did find that neck tension or strain along the axis of the upper cervical spine cord and brainstem is a possible mechanism of brain injury in concussion.

Cervicogenic Dizziness, Cervical Vertigo
http://www.iccseminars.com

Don’t always imply a neck injury results in a brain injury, but also don’t imply lack of direct head collision means less stress to the cervical spine.  You may just be missing a key component in manual and/or sensorimotor rehabilitation to get maximal results in your patients.


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 

What percentage of patients post-mTBI have neck pain and dizziness?

Cervicogenic Dizziness, Cervical Vertigo

It is well known now that majority of individuals resolve following a mTBI (mild Traumatic Brain Injury), collectively can be a concussion and/or whiplash, within 10-14 days.  However, a certain percentage of patients still have symptoms post-mTBI, better known as post-concussive syndrome (or post-concussive symptoms).  In post-concussion, nearly half of patients report significant persistent symptoms at one-year post-injury.

There are multiple systems involved with mTBI and post-mTBI symptoms can involve visual, sensorimotor, peripheral, central and cervical origin.  These impairments vary between individuals but several common symptoms seen in a physical therapist’s office are headaches, dizziness and neck pain, as well as fatigue and other cognitive deficits.

The latter two are what we address under the umbrella term of Cervicogenic Dizziness, especially if the neck pain is causing, or part of (such as double entity) of the dizziness symptoms.  The cause and treatment of headaches can be multimodal and not a major part of our discussion within this expertise or within our courses.

Cervicogenic Dizziness, Cervical Vertigo, BPPV, Dizziness, Cervical Spine, Concussion
Integrative Clinical Concepts. Drs. Harrison & Danielle Vaughan

What percentage of patients post-mTBI have still have neck pain and dizziness?

Recently, Galea and colleagues in 2019 examined several validated impairment specific self-report clinical tools (referred to as impairment specific tools) in symptomatic mTBI, asymptomatic mTBI, and healthy controls.  For regards to this post, these self-reported clinical tools are the Neck Disability Index and Dizziness Handicap Inventory, for neck pain/disability & dizziness respectively.

A substantial proportion of individuals (79% overall) in the mTBI group reported clinically relevant scores on one or more of the impairment specific tools compared to healthy controls (12.5% overall).

In relevance to Cervicogenic Dizziness:

Fifty percent of individuals post mTBI (76% symptomatic and 21% asymptomatic) reported clinically relevant levels of neck pain and disability, and 45% (70% symptomatic and 17% asymptomatic) reported clinically relevant levels of dizziness associated handicap.

Cervicogenic Dizziness, Cervical Vertigo, Concussion, mTBI, Whiplash
Red box: Neck Disability Index & Dizziness Handicap Inventory for HC (Healthy Control), Asymptomatic mTBI & Symptomatic mTBI Blue: Number of patients within those groups who meet significant cut-off score for being relevant

Here is an interesting quote from the article,

Overall higher levels of neck disability and hyperarousal were observed in the asymptomatic mTBI group compared to the healthy control group (p < 0.05). These results indicate that individuals may not recognise the persistence of symptoms post- mTBI.

The bolded statement is very interesting to me.  This says clinically that if a therapist just asks a patient if she/he has neck pain or dizziness, without objectively assessing it (via self-report measure or more simply through a manual assessment), then you may get a false negative!  

Symptoms may also be present in individuals who overall consider themselves symptom-free. The false negative leads to no treatment, or minimal treatment, for the neck pain and/or dizziness and therefore lead to further impairment as not addressed by the specialist!

Quote from the author’s in conclusion:

Potentially generic self-reported symptom scales may not detect symptoms in these apparently asymptomatic individuals, questioning their appropriateness in determining recovery and ability to return to activity post-mTBI.

I wonder, in addition to self-report measures, if you assess the cervical spine in an asymptomatic, or symptomatic patient to determine if ability to return to activity and/or discharge from clinical care for:

  1. Pain pressure threshold to palpation over C0-3
  2. Pain pressure threshold to palpation over suboccipital musculature
  3. Two-point discrimination to the upper cervical spine

This is not just us talking, but this EXACTLY what Jennifer Reneker and colleagues did with patients suffering from dizziness after sports-related concussion in 2018. They found that 82.9% of patients had examination findings consistent with cervical dysfunction and actually diagnosed 26.8% of patients with actual cervicogenic dizziness.

Either you perform it with a specific self-report measure or with manual examination skills…but please do one of the other and not just “ask” if having neck pain or dizziness with this population as you will potentially miss very important and very treatable remaining symptoms.


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

 

Why do some BPPV patients require more repositioning procedures for relief?

Cervicogenic Dizziness, Cervical Vertigo

Treatment of BPPV can be one of the most rewarding procedures in the field of physical therapy — both for the patient but also the clinician!  There are not many instances in our profession that we can make life changing results in just one visit!

When the diagnosis of posterior canal BPPV (most common canal involved) is made through history taking and clinical examination, the application of canalith repositioning procedure can be effectively performed with success rate as high as 80%.  However, for some individuals, repeated manuevers are necessary to achieve results.

The question is, why?

This has been studied over the years with conflicting results over factors including:

  • Age
  • Which canal is involved
  • Duration of symptoms
  • Intensity of symptoms and
  • Comorbidities (diabetes, high blood pressure, migraines, etc)

For most vestibular therapists, the application of two canalith repositioning manuevers are performed in the same day.  If the second diagnostic test (i.e. Dix-Hallpike) is negative, we can be more confident of best results as the Epley Manuever (or comparable procedure for a different canal) was successful.  We would reach out to say this is a fair assessment of a typical treatment regimen.

So, for those requiring more than one or two procedures– the question remains — is the issue in a different canal, is the issue due to chronicity of symptoms, is the issue due to age, etc etc?

I want to invite you to Korkmaz & Korkmaz’s retrospective study  in 2015, entitled, “Cases requiring increased number of repositioning maneuvers in benign paroxysmal positional vertigo“.

These authors studied this exact question, and found the following conclusion:

Our study showed that patients with hypertension required higher number of treatment visits compared to patients with no hypertension….The presence of hypertension is a risk factor for repeated maneuvers in BPPV treatment. When dealing with patients with hypertension, physicians must be aware of the high probability of repeated treatment sessions.

So for us in rehabilitation medicine, we of course cannot diagnose hypertension NOR treat it via pharmacological methods….so you may ask, okay…I see this day to day in the clinic but what can I DO about it.

We all know hypertension is a major vascular condition and can obviously hinder blood perfusion through the arterial system, especially smaller vessels inserting into the vestibular organs.  Some clinicians express that the ischemia from hypertension may cause more extensive otolithic debris formation than usual and that may be why multiple maneuvers are needed to reposition the otolithic particles in these group of patients.

Image result for acupuncture dizziness neck

To go outside of the physical therapy, even chiropractic and osteopathic literature, as well-rounded clinicians, we should enter the information from the acupuncture works.  The use of acupuncture has been used for chronic dizziness for over three thousand years (vs PT Epley Manuever starting in 1983, Chiropractic in 1890s & Osteopathic in 1870s).  The point of this post is not to delve into the practice of acupuncture, but to simply educate others in our profession of other potential treatments and why.

The mechanisms behind traditional acupuncture is WAY beyond the means of this post (and not the point as not my speciality), but for the most part, we can capture that increased blood flow and circulation (alleviate insufficiency potentially caused by hypertension) in the vertebral – basilar artery (and subsequently downstream to vestibular organs) is a MAJOR pathogenesis mechanism of results following acupuncture for dizziness.

So, if for thousands of years, the treatment of dizziness can be attributed to blood flow and circulation—treated with acupuncture and other methods—and the recent work of Korkmaz & Korkmaz showing the highest risk factor for more treatments to improve same diagnosis is hypertension — why would it not be plausible to combine manual therapies to the cervical spine IN ADDITION TO canalith repositioning procedures (which is accompanied by treatment clinical guidelines) to potentially reduce number of repositioning procedures and get faster results?

If you think along these concepts, and add that the #1 comorbidity in Korkmaz & Korkmaz’s study is spine problems (over 1/3 of patients!) — how could you think that is is not feasible to combine both manual therapies (to the cervical spine) and vestibular therapies for the most effective treatment of BPPV?

This is WHY we bring in the best of the best in manual therapies and vestibular therapies for those suffering from dizziness.  Let’s not even call it Cervicogenic Dizziness — but simply Dizziness.

You will not get the combination of manual therapy, vestibular and sensorimotor training anywhere else! Learn more how to get the best results in your patients!

Stay tuned to future blog describing evidence for increased blood flow and circulation following manual therapies.


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

Why is recent infection a precaution to orthopaedic manual therapy?

Cervicogenic Dizziness, Cervical Vertigo

In the field of Orthopaedic Manual Therapy, one of the first things we learn are contraindications (relative and absolute) and precautions prior to performing a procedure.  A full list of cautionary measures is beyond this blog post, but one I want to bring to attention is recent infection (particularly throat injection).

In conventional clinical reasoning, a recent infection is associated with a risk factor (recent event) for cervical instability but substantially more dangerous of a condition, with fatal consequences, is the arrival of a spontaneous cervical artery dissection.  Frankly speaking, this could be the start of a stroke in process and is an absolute contraindication to physical therapy (or even chiropractic, massage, osteopathic, etc) treatment; but requires medical intervention.

We do know there are some risk factors, including trivial trauma (minor and major) and symptomology associated with increased suspicion of a spontaneous cervical artery dissection in process.  One risk factor that continues to arise in the literature but not as confirmatory of a dissection prospect, at least compared to other factors of vascular turbulence, is connective tissue disorders.

I want to send the readers over to a recent article by James Demetrious in the Chiropractic & Manual Therapies Journal (2018).  He examines the thought & reasoning process that Fluoroquinolone antibiotics constitute a risk factor for cervical artery dissections.  I recommend reading the article (it’s short AND free) for full details but I want to highlight a quote from the article:

It is plausible that fluoroquinolones may incite connective tissue degradation and play a contributory role in the genesis of cervical artery dissections…..A causal relationship of fluoroquinolone antibiotics to cervical artery dissection is plausible. Fluoroquinolones may indeed be a novel and previously unrecognized cause of cervical artery dissections.

So you may ask, what is the relationship with recent infection??

—>the patient will of course go to a medical physician for potential infection

—>>potentially be prescribed this class of medication (which can cause degradation of connective tissues)

–>> then may or may not have trivial trauma and seek out your consultation and treatment for headache, dizziness, neck pain, etc.

There is definitely more research needed on this topic but I found this to be an intriguing article and confirms more precaution should go through a clinician’s mind and reasoning process when a patient has recently had an infection.

In our Cervicogenic Dizziness Course, we go over our Optimal Sequence Algorithm on the first day; which gives you the best of the best in the literature associating risk factors, symptomology & clinical examination procedures to make sure you are confident that the patient in front of you has a mechanical disorder.  We find it is a must when dealing with the intimidating field of dizziness, especially if you aim to address the upper cervical spine.


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

 

Do THIS before performing Dix-Hallpike Manuever

Cervicogenic Dizziness, Cervical Vertigo

The Dix-Hallpike Manuever is  considered the gold standard for the diagnosis of posterior semicircular canal Benign Paroxysmal Positional Vertigo (BPPV).  It has decent statistics in its utility in just itself having a sensitivity of 79%, specificity of 75%, LR+ = 3.17 and LR- = 0.28  (Haulker et al 2008) and lends itself very convenient for smooth transition into treatment via the Epley Manuever.

In addition to a thorough patient history, this patient examination piece is crucial in clinical practice guidelines by Bhattacharyya N et al 2008 to assist clinicians in the grey zone of dizziness symptoms.  Agreeing with this work and consensus among clinicians, the practitioner should absolutely differentiate between this benign condition with other, potentially dangerous, reasons for imbalance, vertigo and dizziness.

One of the biggest take-aways I get from our Cervicogenic Dizziness Diagnosis & Treatment weekend course is most “vestibular” clinicians get an “a-ha moment” while learning the Optimal Sequence Algorithm, particularly Appendix C (Cervical Artery Dysfunction)  I say “a-ha” lightly; meaning not to fray upon their current clinical decision making, but the reason WHY we teach ruling out Cervical Artery Dysfunction prior to performing peripheral testing and cervical ROM testing.

We teach a very simple, but effective means to rule out vascular insufficiency (clinical exam) & conditions of spontaneous origin (most likely what will walk in your door) based off of concepts of epidemiology, entire body hemodynamic principles, and triggers to possible cause of a dissection.

Diagnosis of Cervicogenic Dizziness
Cervicogenic Dizziness. Optimal Sequence Algorithm. Integrative Clinical Concepts. All Rights Reserved.

This is a huge interest of Harrison’s considering the changes in thought-processes and clinical-decision-making of relationship between manual therapy  and stroke over the past decade.  Many myths were put to rest in Harrison’s training early in his career that ballooned into more understanding by his Fellowship Mentor, co-author of the Optimal Sequence Algorithm for and ICC partner, Dr. Brent Harper.  Considering Danielle and Harrison come from “different” backgrounds (vestibular and manual training, respectively); we found a missing link in this understanding and present it very clearly in our course.

Openly speaking, causing a stroke from manual therapy is MUCH more prevalent in discussions on this topic compared to performing vestibular rehabilitation of canalith repositioning testing and treating — even though a spontaneous dissection in process could turn dangerous with even these procedures.  Hence why we our course is called, “Bridging the Gap between Manual and Vestibular Therapies”.

Cervicogenic Dizziness, Cervical Vertigo, BPPV, Dizziness, Cervical Spine, Concussion
Integrative Clinical Concepts. Drs. Harrison & Danielle Vaughan

Watch the video attached to this blog of a clip from a short lecture of Harrison speaking at our course describing why it is pertinent to consider vascular origin, specifically spontaneous dissection, with symptoms of dizziness/imbalance/vertigo prior to performing Dix-Hallpike Manuever in patients suspected of BPPV.  Learn this approach to be the most confident in your clinical examination of patients presenting with dizziness, even if your plan is to perform a joint mobilization/manipulation, massage or canalith testing.


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

Stroke following cupping therapy AND a massage? WHAT?!

Cervicogenic Dizziness, Cervical Vertigo

Historically speaking, most practitioners in medicine contribute cervical artery dissection (potentially lead to stroke) to manipulation of the cervical spine–especially from the chiropractic profession.  Several come to my mind including Grant 1987/88, Drueger & Okazaki 1980, Terrett 1987, Hurwitz 1996. This was echoed through the years from emergency medicine physicians in case reports, case series and case control studies but in the last decade, our knowledge on this phenomenon has changed our perspective of the cause.

We now know from the works of many authors, but especially the case-crossover design work of Cassidy in 2008 and reflected again in 2017; that most likely a patient is arriving to your clinic with a stroke in progress.  Briefly speaking, the practitioner must have felt the symptoms were musculoskeletal in nature, but instead, were of vascular nocioception and the headache/dizziness/etc was the symptom that led the individual to seek out help.  Basically, a potentially fatal condition was missed.  For us in the industry who keep up with this data, the trend is leaning towards a more global screening processes including the vascular system to make a more informed decision with positive results, but there are many cases that are still reported, including recently in a Family Practice Journal.

I recently stumbled upon two papers indicating a spontaneous dissection that led a patient to a healthcare provider—in these cases the treatment approach was not manipulation, but cupping and massage.

I can provide full texts to those who wish to read, but here is synopsis:

Choi et al 2016

We report an extremely rare case of spontaneous extracranial VA dissection presenting with posterior neck hematoma aggravated after cupping therapy.

“We presume that when spontaneous extracranial VAD occurred, his neck pain began and the cupping therapy caused a VA rupture and posterior neck hematoma with a pseudoaneurysm.”

Dutta et al 2018

We present an unusual case of vertebral artery dissection in a 30-year-old male patient following an episode of neck massage….The current case demonstrates the hazards associated with neck massage and the potential for good outcomes in these patients if timely intervention is provided.

For those of you who treat headaches, neck pain and dizziness; albeit very rare, you should always keep in mind potential cervical artery dysfunction.  It could arise spontaneously or after a trauma, even trivial.  Although we are still working in a diagnosis and area of uncertainty, I would suggest these two reports correlate with our trend that the actual procedure doesn’t cause the stroke—but instead, the acute arterial event was occurring spontaneously which led to a patient coming to you for help.

In the Optimal Sequence Algorithm of our Cervicogenic Dizziness Course, this is a hot topic and one that I take very seriously.  Alongside my fellowship mentor, Dr. Brent Harper, we have designed what we both find to be the most up-to-date and sound reasoning to rule out spontaneous and mechanical vascular event.  We strive to improve the order of your examination definitely makes a difference — which is one of the major flaws behind the vertebral-basilar insufficiency (VBI) test.

Even though I find our approach is quite sound, I want to end this post with the conclusion from Choi et al 2016 as it is a solid statement and a major take-home point:

The clinical diagnosis of VAD is not easy with acute-onset neck pain, especially young patients with no evidence of cervical trauma and disease. With undiagnosed VAD, traditional remedies such as cupping and chiropractic therapy to reduce pain can aggravate spontaneous dissection and worsen symptoms…..Early diagnosis of VAD could prevent symptom aggravation and permanent neurologic deficit.


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the author and his wife, a Vestibular Specialist, teach a 2-day course.  Pertinent to this blog post, the first day provides the most up-to-date evidence review from multiple disciplines to diagnose through the “Optimal Sequence Algorithm” to assist in ruling out disorders and ruling in cervical spine, including determining if single or double entity exists.  

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 prices and discounts.

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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?

Cervicogenic Dizziness, Cervical Vertigo

When considering dizziness of cervical origin, it is well accepted in clinical practice to follow the rule of “diagnosis of exclusion”.  This means that you can suspect, but not confirm, dizziness or vertigo from the neck unless you rule out other competing diagnoses.

It is thrown around from ones who try to invalidate the condition that up to 90% of cases can have a convincing alternative diagnosis.  Additionally, Cervicogenic Dizziness can affect populations across the lifespan with traumatic and even non-traumatic origin. Therefore, the prevalence of Cervicogenic Dizziness can be challenging to truly calculate.

However, we can reach out to the literature to provide some input on how frequent patients have Cervicogenic Dizziness.  We provide a synopsis for you below to help with prevalence rates for these subcategories.

Elderly / Geriatrics

A classic study cited in most often comes from Colledge et al in 1996 in BMJ.  This is a community based study looking at causes of dizziness in elderly patients in primary care practice.  The investigators found that 30% of total patients had dizziness symptoms and contributed 66% of those cases to cervical spondylosis (arthritis).  Two-thirds of the patients with dizziness coming from the neck is a significant proportion!

A more recent study by Sho Takahashi in 2018 retrospectively examined the cause of general dizziness in an outpatient setting.  Out of the 1000 patients, 899 (90%) were found to have cervicogenic general dizziness.  The authors contribute cervical spinal canal stenosis as the culprit in the group with average age of 62 years old.  Wow, 9 out of 10 patients were found to have dizziness coming from the neck!

So yes, the geriatric population, even though with higher proportion of competing diagnoses including peripheral, cardiovascular, and psychological causes; have a high prevalence of Cervicogenic Dizziness.  For therapists out there who are in vestibular rehab / neuro rehab and even home health, this is something to consider!

We can’t forget the data from the concussion and whiplash literature.  Here are some other robust numbers for you:

 

Whiplash

The literature on this is somewhat older but still very pertinent, stands true to today, and actually we have more data from multiple sources.  I always say about half of patients who have had whiplash-associated disorder experience dizziness and/or imbalance. To name a few, I recommend reading the works of Diane Wrisley 2000, Oostesteveld et al 1991, Skovron 1998, Humphreys & Peterson 2013. 

Non-Traumatic Cervicogenic Dizziness

For those who are not treating the elderly and not dealing with trauma, the numbers are not nearly as hefty.  I always mention to my students that the prevalence in this realm is ~10%.  Even though the patient age and criteria within these studies vary, I lump this under non-traumatic Cervicogenic Dizziness. This is where I get my data:

Ardic et al 2006, in a retrospective chart review, noted dizziness of cervical origin at 7.5%.

Luscher et al 2014, in a prospective, observational, multi-center study, noted dizziness of cervical origin at 6.4%.

Reid et al 2015, in a randomized-controlled trial, had 8.5% of participants fulfill the inclusion and exclusion criteria as having Cervicogenic Dizziness.

From the outside looking in, the literature is all over the place with our prevalence numbers!  This is what makes the condition challenging and exciting to treat and help others.  You can consider Cervicogenic Dizziness as a single entity, double entity and even traumatic vs non-traumatic origin. Therefore, the prevalence of Cervicogenic Dizziness can be challenging to truly calculate.  I hope this information helps you make a better decision in the office.


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

 

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