Cervicogenic Dizziness – Controversial Entity between Professions

Cervicogenic Dizziness, Cervical Vertigo

There is controversy between professions.


Gonzalez and Palacios in 2001 wrote an article, “Cervical Dizziness: A Scientific Controversy” in Fisiotherapia Journal.  The final wording in the manuscript, albeit translated from Spanish to English, basically sums of the controversy that surrounds the diagnosis and treatment of cervicogenic dizziness in one sentence.

For practitioners of physiotherapy and manual medicine, the vertigo of cervical origin is almost unquestioned, treatable and solvable entity mostly, while for professionals otolaryngology and scholars of the vestibular apparatus and balance, their relationship remains hypothetical and in many cases questionable.

Gonzales and Palacios 2001


There is controversy between professions.


To those in the professions of manual medicine and rehab—osteopathy, acupuncture, chiropractic and physical therapy—the diagnosis and treatment of cervicogenic dizziness obviously occurs and can be present in many subsets of different populations.  To anyone who has dealt with this in their office, this seems to be a no brainer as results speak for themselves.  However, outside the manual medicines, including otoneurology and audiology; the diagnosis of exclusion stands concrete and likelihood of referring out is much less likely.  In fact, most of the literature denotes less than a 10% prevalence rate with dizziness from cervical origin and majority of studies consistently outside of the rehabilitation and manual realm do not list it at all under differential diagnosis.

Could cervicogenic dizziness be embellished in the manual medicine fields and neglected in the allopathic medical field?

cervical vertigo, cervicogenic dizziness
Cheever et al 2016

The question remains, what makes the incidence and prevalence so different between the professions?

Is it a business argument?  Obviously manual medicine and rehab can benefit from treating these patients, where medication and imaging does not work.

Is it science?  The diagnosis of dizziness from a cervical origin continues to be under debate and scrutinized (Brandt 1996, Brandt/Bronstein 2001).  There is a discrepancy in the pathophysiology, lack of diagnostic criteria including a well established clinical test or a specific laboratory test, and many other diagnoses can be a convincing alternative reason for symptoms.

Is it ethical?  With a lack of a true diagnostic test, unknown epidemiological data points and prognostic time line of improvement—could the manual medicine fields provide unethical treatments— scientific implausible treatments or even fraud?

Is it training?  Anyone in the physical therapy field knows the lack of training in the MSK field by physicians—we fuss about this all of the time.  We contend about their lack of knowledge to refer to us for even less controversial diagnoses.  You can imagine, considering even a small percentage of manual medicine that focuses on cervicogenic dizziness, that medical physicians do not have training or knowledge to refer out to us for this condition.  Just recently, Reneker et al 2015 found a distinct difference between professions regarding utility of clinically diagnostic tests for differentiating cervical and other causes of dizziness s/p concussion.  In fact, three tests, 1) passive joint mobilization, 2) palpation of cervical musculature and 3) joint position error testing were shown to have high utility to diagnose cervicogenic dizziness by PTs (62%, 53% and 47% respectively), but NONE of these were selected by a single neuro-otologist!


There is controversy between professions.


With such discrepancies between the philosophies and clinical approaches between the medical trades, it is no wonder there is never “cervicogenic dizziness / cervical vertigo” is not on a script.  We must meet on the same playing field here and see both sides of the argument with the manual and non-manual fields.

A fair result can only be obtained only by fully stating and balancing the facts and arguments on both sides of each question.

Charles Darwin

It can be challenging to go speak to physicians about this condition as we do not have the juice to provide in regards to evidence.  However, this is an emerging area of practice and the physical therapy field is gaining traction in RCTs by Susan Reid’s work to put more power to our trade.  With that being said, if you want to learn the evidence to present to physicians, either in the elderly, s/p concussion, s/p whiplash or some other head/neck insult—we got you covered because there is controversy between professions. 

 

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 entire weekend includes the most up-to-date evidence review from multiple disciplines to diagnose through the “Optimal Sequence Algorithm” and treat through the “Physio Blend”. 

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.

Authors

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Physical Therapist at In Touch Therapy, South Hill, VA

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Vestibular Physical Therapist at Drayer Neurological Clinic, Raleigh, NC

 

 

Cervicogenic Dizziness – should you treat the upper trapezius?

Cervicogenic Dizziness, Cervical Vertigo

trap

Simons and Travel 1999 describe myofascial pain (MP) as a common symptom usually caused by myofascial trigger points (MTrPs). The MTrPs in the neck muscles have been associated with a possible source of referred facial and cranial pain and could contribute to the nocioceptive activity occurring with Cervicogenic Dizziness.  The muscle most often affected with the presence of MTrPs in the neck region is the trapezius muscle,  specifically the upper fibers, and this is the most hyperalgesic muscle of the neck and shoulder (Sciotti et al 2001, Melegar & Krivickas 2007, Fischer 1987).  In fact, it is well established that treating soft tissue dysfunction of the upper trapezius is effective in the management of nonspecific cervical pain (Cagnie et al 2015,  Montañez-Aguilera FJ et al 2010Aguilera FJ et al 2009).

The authors of this manuscript consider addressing MTrPs in the descending fibers of the upper trapezius to be an appropriate treatment for individuals suffering from Cervicogenic Dizziness, however, it may be incomplete and suboptimal location to maximize potential outcomes.   It can have an influence on the functional relevance of the neck in its relationship with the cervico-collic reflex and vestibulo-collic reflex, but may not be a significant factor in modulation of its effects on head-in-space and head-on-trunk posture. All things considered, even though it is a popular location to stretch or treat manually, it may not be as much of a contributing factor of nocioceptive input into dysfunction of head on neck proprioception and self-motion perception.

The following two scenarios are the theoretical concepts to this impression:

  1. Relative Abundance of Muscle Spindles

Neck muscles are richly endowed with muscle spindles and contribute greatly to proprioception of the neck (Voss 1958, Cooper 1963, Kuklarni et al 2001Liu et al 2003).  The high muscle spindle density and the special features of the muscle spindles in the deep neck muscles allow not only great precision of movement but also adequate proprioceptive information needed both for control of head position and movements and for eye/ head movement coordination.

The number of muscle spindles in relation to muscle mass in a recent anatomical study by Banks RW 2006 confirms the greatest abundance is in axial muscles, including those concerned with head position.  The upper trapezius muscle is a high contributor of muscle spindles, but comparably, it is far behind suboccipital musculature, being rated #31 and along the same relative abundance as the adductor pollicis, extensor digitorum brevis, obliquees internus abdominus, omohyoideus, pronator quadratrus and extensor digitorum.  These muscles, due to their location, are of course not primary influence on head-on-neck proprioception.

So, based off of this information and overall thoughts on a patient’s adherence to a home program (keeping 5 exercises or less)— does stretching the upper trapezius, as described in the literature & pictured below, appear to be the most optimal treatment & one we should encourage with patients having cervicogenic dizziness?

trap
Minguez-Zuazo, et al 2016, Malmström et al., 2007; Schenk et al., 2006; Wrisley et al., 2000

2. Influence based off of points of attachment on occiput (from Dvorak J. Manuelle Medizin. 1988)

points of attachment

Based off of the cross section of the occipital anatomy shown above, you can question the influence of the upper trapezius, as compared to suboccipital musculature, on the effect of head on neck posture/proprioception.  The surface area of the upper trapezius is significantly less than other muscles of the cervical spine, especially short dorsal musculature of the upper neck.  Therefore, we must take into account the overall influence of the upper trapezius compared to other musculature to optimize patient outcomes and results to improve pain, joint position error and postural stability.

Thus, the theoretical constructs and literature review for the non-articular management of cervicogenic dizziness is unclear and still under scrutiny.   The application of soft tissue management at one location vs another can be determined through a thorough clinical reasoning process and assessment  The type of soft tissue intervention that is most optimal (i.e. dry needling, ischaemic compression, IASTYM, dry cupping, deep massage, etc.) is still under debate, but the authors of this post do feel the location of your intervention can make a difference.

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 prices and discounts.

Authors

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Physical Therapist at In Touch Therapy, South Hill, VA

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Vestibular Physical Therapist at Drayer Neurological Clinic, Raleigh, NC

 

 

 

In Touch Therapy is hiring!

If my readers (or colleagues of readers) are looking for a fantastic job opportunity (new grads or seasoned), the company I have been with for 9 yrs is hiring.

Working at one location for 9 yrs is unheard of nowadays—and there are many reasons why I am still here! Here are a few highlights:

  •  1:1 time with patients
  • low stressful environment
  • Patient load varies and never same old “post-op rehab!

Please pass on!

Here is our ad:

In Touch Therapy (South Hill, VA) has been making a difference in people’s lives since 2002. We are looking for the right person to join the ITT team. Help us grow our orthopedic/manual Physical Therapy out-patient center. Flexible schedules, monthly production bonuses, health/dental/vision package, matching retirement, and PTO. Our skilled professional team works together to create a learning/teaching environment. We are looking for a positive, driven team member who wants to help people and is eager to learn. Current VA license required. Please email resume, including references, to Marie Walker mariewalkeritt@gmail.com.

Posted in Uncategorized

Re-Sensitization is where it’s at

central sensitization

Unless you’ve been under a rock as a clinician, the term ‘central sensitization’ should be in your vocabulary.  It has gained popularity through the cycle of pain science, especially over the past 5-10 years.  Even though it appears central sensitization is new and sexy, it is not a modern term, and to my knowledge, the seminal paper on it by Dr. Woolfe goes all of the way back to 1983. Much change and marketing has happened in this 33 year span, but even still, the thought process of this term has been around for centuries.

central sensitization

You can find 6 ways to Sunday to explain this phenomenon to your patients, which I do using my “Pain Cartesian Scale (here too).  I encourage you to find the best way to translate this to your patients in the context they need to understand.  My colleague and friend, Dr. Matt Dancigers, explains this better than anyone else I know.  I highly recommend reading his blog.

Nevertheless, I find the explanation of central sensitization to be somewhat limiting to achieving better outcomes for my patients.  Don’t get me wrong, it does help, but not an extraordinary game changer.  What I find works better in clinical practice is the term, “Re-sensitization”.  This is an ad-on to central sensitization and of course has to go alongside it in your education, but seems to be more of a heavy hitter in regards to applicability for the individual—especially after he/she has felt results and gained your trust.

In a nutshell, the way I assimilate Re-sensitization to patients is one they understand—it is an exacerbation of symptoms.  We all know this happens for any condition, but especially chronic pain.  I translate the importance of a healthy diet, stress reduction and general exercise, of ways to reduce re-sensitization—-this is a multi system issue (endocrine, metabolic, cardiovascular, etc) and not just musculoskeletal.  But for the main purpose of my point in this post, I recommend  focusing on a specific HEP based off of what worked for the patient under a course of care.

In some individuals, a general exercise program at a gym may just do it.  But what I find, and I’m sure many of you, is that you need something specific for the area/region that seems to be the one that is picked at the most.  It could be a neural glide, self-mobilization, myofascial ischaemic compression, etc etc—-but your job, and what I get most out of the umbrella term of sensitization, is to find and prescribe what works with the upmost confidence and highest power to desensitize the system to prevent re-sensitization.

It works like this: Peripheral sensitization leads to Central sensitization—-we can ramp down this entire system (and local region) through our interventions—-but then Re-sensitization occurs over a course of Time—this is where intervention is needed again—by either specific HEP and or Therapist Treatment.

resensitization

It is challenging to put more concepts into words and make it applicable to your setting, approach, and patient type.  But, I do hope you are learning more about central sensitization and now the phrase re-sensitization—which has been successful for me in the science of pain.  It also helps me establish a wellness program and principle of coming back to me vs medication/physician/surgeon if exacerbation occur as an overall successful business plan.

As an added bonus for reading my blog,, I am offering a FREE, 30 min, E-mentorship session for anyone who feels they would like more information on re-sensitization, but also mentorship and guidance on complicated cases.  Just email me at harrisonvaughanpt@gmail.com with “re-sensitization” in subject line. You may just find it to be beneficial and would like to go through a mentoring process. Feel free to contact me for more information and read about the Program more on my E-mentorship page.

 

 

 

 

What angle are you addressing your patients?

There is an old saying in the orthopedic manual world that goes to the tune of:”You can teach a monkey how to manipulate, but not why and when to manipulate”

Any clinician who has been around the realm of manipulation in clinical practice can relate to this statement. However, I think it can apply to other aspects of our care too. Let me give you an example.
During one of my recent e-mentorship sessions, my mentee was providing me a story of a patient who is seeking his care after failure to improve following 4 weeks at another facility. This individual is diagnosed with achilles tendinosis.
What comes to mind when treating this diagnosis?
I guarantee a large percentage of you, including myself, jolt with excitement and say, “eccentric training!”

We say it without much thought as it is what the research says works. The highest of the evidence pyramid glows with excitement.  

But in this case…it didn’t work. The patient wasn’t satisfied…the outcomes were not positive. The patient decided to seek out a cash based service.  

Fast forward a few treatments — patient recovered and returned to soccer.

So what was the difference?

I can’t take the credit as my mentee did a full examination and came up with a plan of care. He did it all and came from a different thinking process.  I can say that the treatment was based on concepts and principles. These concepts and principles that have been around for decades and do not fail.  

So what’s the moral of the story?
“You can teach a monkey to read the research, but not why and when to use the research”
Literary articles are intended to be another layer to your treatment to justify it even further based on your assessment using concepts and principles. In this case, the research was the first layer versus secondary or tertiary layer.  In this age of evidence , I continue to urge the importance but at a different layer.  
If you find yourself doing the following:

Give my e-mentorship program a shot. I personally believe you are attacking the problem from the wrong angle. 

Let’s work together to get your patients better— quicker — give them that experience we all look forward and spread the good news.  
Next time you want to spend $100 on a local continuing education course for a day, give me time once/week for a month.  I guarantee it’ll change your thinking process and up your game.  Contact me so we can work together personally to make you a better clinician and get the outcomes your patients deserve. 

Don’t Chicken Out! Prescribe “Clucking” to Your TMD Patients

I recently nerded it up from home and on the go while learning about TMJ disorders and treatment approaches from the Manual Therapist himself, Dr. Erson Religioso.  The following is my analysis from Dr. Religioso’s Eclectic Approach to TMJ Disorders. 

If you would like access to 600 accredited courses and growing from the comfort of your home, as well as patient education models, and HEP software—and you like my stuff….be sure to use my affiliate link, inTOUCH, in order to save $100 off A YEAR for the low price of $200 for access to continuing education through MedBridge.  Not a bad deal at all!

The following blog post originally appeared on MedBridge Education’s blog on July 6, 2016.  Click the previous link for access to a 2 minute clip on tongue resting position.

From my experience teaching interns in the clinic, they are normally nervous about treating temporomandibular joint disorder (TMD) as it is typically not covered at physical therapy school. In the video segment below, Dr. Erson Religioso III takes a simple, yet productive approach to explaining the problematic TMD condition.

Dr. Religioso’s course is a great introduction for new graduates and a detailed refresher for experienced clinicians. His knowledge of the TMJ and its relationship with the upper cervical spine is simplified in a digestible manner that allows the learner to step away from the screen and perform effective treatments immediately.

A Diversified Approach

The course focuses on treating the patient by decreasing threat and tone through an eclectic orthopedic manual therapy methodology. You will learn the relationship of posture to TMJ, education through “clucking”, and several other effective approaches to patient care. Moreover, because Dr. Religioso’s work incorporates interdisciplinary techniques, he is able to answer numerous clinical questions:

  • Why should the movement screening come before the repeated movement exam?
  • Why does he try to relieve pain rather than produce pain?
  • Why does he place his hand over the maxilla vs mandibular (not just due to pain over the TMJ)? Hint: The biomechanical component!
  • Why can loading the joint with repeated movements assist in re-setting the central nervous system better than unloading the joint? Hint: It’s opposite of what most clinicians do!
  • Why using a tool can inhibit tone better than hands/fingers?
  • Why certain soft tissue patterns are effective in individuals with high tone vs low tone?
  • Why does he use soft tissue work first in the treatment sequence?
  • Why is working on soft tissue on ipsilateral side vs contralateral side (where we normally would stretch as “tight” tissues) a better approach?
  • Why does regional interdependence play a huge role in treating TMD and in soft tissue mobilization techniques to multiple patterns of the upper quarter?

Besides the answers to all of these questions, Dr. Religioso also focuses on patient education of posture, neck position, and the cause/effect for patients to keep improvements.

If you have read his blog, you will hear echoes of Dr. Religioso’s writings in his voice as he describes what worked for him in treating TMD over many years. His advanced training by Dr. Racabado, one of the pioneers of TMD in the states, is evident in his course.

Clear & Confident Treatment Strategies

As physical therapists, we know that manual therapy, exercise, and education are key components to overall patient care. The treatment of TMD is no exception. Home exercise programs fuel the patient’s retention from short-term manual relief. This course reinforces that essential message for therapists. “Clucking” is a fundamental aspect of the HEP that I took away. What will be yours?

Thanks everyone for reading! Continue to aim high and finish strong.

In Touch Therapy – full time PT position available 

The team at In Touch Therapy in South Hill, VA is continuing to seek out the right Physical Therapist candidate for our growing practice.  I want to send out an offer to my readers (who can then pass the word of someone you know) once more before advertising through typical means.  We would like to have someone who has interest in topics that I have written about in the past on the blog and looking to advance their clinical skills through in-house mentorship by myself and owner, Dr. David Love.  

This is a fantastic opportunity for a new grad or even a seasoned clinician who just feels like they are doing “same ol thing” and not getting challenged at their current position.  I rarely see your post-op patient for just exercises. You will see a very unique case load with high percentage of direct access and even chronic pain that gives you that self-satisfaction of making a difference everyday.  
Feel free to contact me at harrisonvaughanpt@gmail.com for questions or more information. 

The following is our formal advertisement. 

Our private practice has been making a difference since 2002 – join the ITT team! Help us continue to grow our orthopedic/manual therapy based outpatient center. New grads and seasoned professionals welcome. 1:1 treatment times are coupled with mentorship and collaboration with experienced clinicians for a rewarding work environment. We are looking for positive, driven team members who want to help people and are eager to learn from one another. Flexible schedules, monthly production bonuses, health/dental/vision package, matching retirement, and PTO. Current VA license required. 

Posted in Uncategorized

Introducing Integrative Clinical Concept’s Summer Tour

I am pleased to announce the inaugural start and end of summer 2016 tour of a new continuing education company, Integrative Clinical Concepts (ICC)!

For those of you in the states of Virginia/North Carolina,Dr. Alex Siyufy and Dr. Jake McCrowell will be teaching in both capitals, Raleigh and Richmond, in August & September.

This is a fantastic opportunity to learn both soft tissue mobilization techniques and how to integrate manual therapy into higher level motor control exercises for the athletic population.

Early bird rate of $225 (regular rate $245) ends July 17, so get on it if you want to attend!

Feel free to contact me at harrison@iccseminars.com if you have any questions.

FullSizeRender (2)

marketing

APTA Launches #ChoosePT Opioids Campaign

All,

Just received email from APTA promoting a new campaign to position PT as a safe and effective intervention for chronic pain instead of opioids.

In case you do not get emails from APTA or follow through social media, I am forwarding the email below.

I deal with chronic pain on a daily basis and it is an uphill battle of course but we have the best measures conservatively to help our patients with minimum to no use of prescription medication.  Continue to aim high!

———————————————————————-

 

Hi, all:

 

Today, APTA launched a campaign called #ChoosePT to position physical therapists as a safe and effective alternative to prescription opioids for long-term pain management. For the past six months, we’ve been planning the campaign, which includes elements of paid, earned, social and owned media. Here is a link to the press release, http://prn.to/1X72HPe.

 

While APTA will initially focus outreach in states where the CDC has identified high abuse and opioid prescribing trends, this is a nationwide effort to position PT as part of the solution. Coincidentally, opioids have taken a tremendous toll on families and communities in Tennessee, so we strategically chose to launch the campaign in Nashville, while we’re in town for NEXT Conference and Expo. We’ve placed four outdoor billboards in high traffic areas on I-40 going into and out of Nashville and they will be up through July 6. The Country Music Festival and Bonnaroo attracts hundreds of thousands to this area during this time.

 

Other elements of the campaign include a print PSA distributed nationally to small community newspapers,  a national digital ad buy targeting websites where consumers are searching for health information, a professionally produced and nationally distributed television and radio PSA, social media promotion and engagement, and targeted media relations outreach to reporters covering the opioid epidemic. We will be working with chapters and sections to generate local support for the campaign, specifically during Pain Awareness Month in September and National Physical Therapy Month in October.

 

Please consider supporting this campaign by tweeting and blogging about how PTs treat pain through movement and the importance of patients and health care providers discussing and choosing safer alternatives, including physical therapy.

 

#ChoosePT is both a theme and call-to-action and will be a central part of our consumer campaigns going forward. Here is a link to the landing page, featuring patient tools and resources, www.MoveForwardPT.com/ChoosePT.

 

Let me know if you have any questions.

 

Thank you,

 

 

Erin Wendel-Ritter, APR

Senior Media Relations Specialist

American Physical Therapy Association (APTA)

erinwendel@apta.org

Phone: 703/706-3397

Fax: 703/684-7343

Web: www.MoveForwardPT.com