Impaired Sensorimotor Outcome Measures for Clinicians

Cervicogenic Dizziness, Cervical Vertigo

Sensorimotor processes are vital for maintaining stability and controlling movements of the head.  Proprioception is typically the most important component of sensorimotor control and is tested clinically in the cervical spine with the joint position error test.  This is generally assessed by measuring repositioning errors when subjects attempt to reproduce specific head positions, and in such tests, subjects are normally blindfolded to remove visual cues.

Cervicogenic Dizziness, Cervical Vertigo, Joint Position Error Testing

The importance of proprioception in the control of movement suggests that any impairment of position or movement sense may have adverse effects on motor control mechanisms, leading to an increased risk of injury.  This is often seen in individuals following a traumatic cervical spine event (such as whiplash or concussion), but also in individuals with non-specific cervical spine pain.  It is often tested in patients with potential diagnosis of Cervicogenic Dizziness.

For those who utilize the joint position error test and the targets to improve motor control know the limitations behind this procedure in full symptom resolution of someone who has Cervicogenic Dizziness.  One of the biggest false-negatives I see is the response to training, which can improve just within a session by performing the same task repeatedly.  This is why the latest research recommends testing rotation and extension 6 times to determine if truly a deficit!

Therefore, I recommend utilizing subjective, impairment specific outcome measures, in addition to objective tests (i.e. Joint Position Error Testing) to not only determine change in your therapeutic interventions, but also to tease out any remaining symptoms that the patient expresses on paper, but not in front of the clinician and is clinically a low-threshold symptom that doesn’t appear on objective tests.

Here are the top 3 Sensorimotor Outcome Measures that you can utilize in the clinic:

1. Dizziness Handicap Inventory (DHI)

The Dizziness Handicap Inventory (DHI) is a validated, self-reported questionnaire, which is widely used to evaluate the functional, emotional, and physical impact of dizziness in patients’ daily life. It consists of 25 questions about daily problems associated with dizziness, and each question is given a score of 0, 2, or 4. It has been shown to be a highly reliable and responsive tool.

A score of 0 means that the condition described in the question never happens, 2 means it sometimes happens, and 4 means it always happens. Following a study by Whitney et al 2004. the DHI scores are graded as mild (0 to 30 points), moderate (31 to 60 points), and severe (61 to 100 points).   A change of more than 10% in a patient’s DHI score demonstrates a clinically significant change over time, and a change of 18 points is considered a true change (Treleaven 2006, Tamber & Wilhelmsen et al 2009).

The Dizziness Handicap Inventory has also been described previously by Susan Reid and colleagues as a diagnostic screening tool to rule in or rule out Cervicogenic Dizziness.

You can download a copy of the DHI here.

2. Visual Complaint Index

The Visual Complaint Index consists of 16 visual symptoms with options to rate frequency and severity on 3 and 4 point rating scales, respectively (Treleaven and Takasaki 2014).

Scores for each item are then multiplied and added overall to achieve a score out of 164. A mean score of 27.4 previously identified in individuals with neck pain (Treleaven and Takasaki 2014) was used to identify clinically relevant vision related complaints.

Symptoms suggesting to be associated with neck pain are more vision related items vs vision specific items.  The following lists the most prevalent to least prevalent in patients with neck pain (Hülse and Holzl, 2000, Kristjansson and Treleaven, 2009, Treleaven and Takasaki 2014):

  1. ‘Needing to concentrate to read’ (most troublesome and prevalent with neck pain)
  2. ‘Blurred vision’ (more specific to whiplash injuries and high levels of pain/dizziness than general neck pain)
  3. ‘Words or objects moving’ (more specific to whiplash injuries and high levels of pain/dizziness than general neck pain)
  4. Difficulty judging distances’ (more specific to whiplash injuries and high levels of pain/dizziness than general neck pain)
  5. ‘Visual fatigue’
  6. ‘Sensitivity to light’
  7. ‘Eye Strain’
  8. ‘Heavy Eyes’

Even though the Visual Complaint Index has not been used specifically in the literature for individuals who suffer from Cervicogenic Dizziness, it can be a useful tool for those who treat patients following whiplash, concussion and mTBI injuries to assist in clinical reasoning behind treating the cervical spine in addition to oculomotor and vestibular rehabilitation.  We recommend utilizing the scale provided below and compare to symptoms provided and objective evaluation above to determine if appropriate to refer out for cervical treatment or even perform yourself.

You can download a copy of the Visual Complaint Index here

3. Space and Motion Discomfort

“Space and motion discomfort” (SMD) describes dizziness that is provoked by visually provocative situations (i.e. grocery stores, malls, ceiling fans). The Space and Motion Discomfort II (SMD II) scale is a 9-item index of space and motion discomfort (Jacob et al., 1993).  In relation to Cervicogenic Dizziness, muscle guarding and limitation in range of motion from altered space and motion discomfort can lead to cervical symptoms associated from disuse.  This is one reason for kinesthetic awareness deficit.

The association between SMD and abnormal balance has been shown to be specific for somatosensory dependence (Jacob et al 2016). Scores for each item (0–3 rating scale) are multiplied by a factor of 10 and summed for cumulative score. A mean total score of 82.4/270 previously recorded in a vestibular population (Jacob et al., 1993) was the nominated clinically relevant threshold.

To date, there are no specific studies utilizing the SMD II with Cervicogenic Dizziness, however, the following visual symptoms included in the index and associated reasons for potential cervical involvement are listed below:

  1. Looking up at tall buildings.  Cervical extension is the most disturbing positional movement associated with Cervicogenic Dizziness.
  2. Leaning far back in chair. Cervical extension (if leaning back involves mostly upper cervical extension vs fluid cervical extension and then upper cervical extension) is the most disturbing positional movement associated with Cervicogenic Dizziness.
  3. Discomfort increase during the day.  Muscular fatigue and disturbance in endurance, especially if in sitting positions all day, are a contributing factor to altered muscular capacity and a symptom of Cervicogenic Dizziness.

You can download a copy of the Space and Motion Discomfort (SMD II) scale here

If you feel your patient is having Sensorimotor disturbances and/or symptoms associated with neck pain, we recommend getting subjective reporting via the above outcome measures.  There are many more in the literature as well but these are the top 3 for Sensorimotor implications.

The treatment of Cervicogenic Dizziness has historically been viewed within a manual therapy construct, but knowing the limitations behind long-term effects of manual therapy and double entity component of dizziness symptoms, we teach specific Sensorimotor exercises for this population.  We find the combination of manual therapy and sensorimotor exercise (not just stretching/strengthening of neck muscles and vestibular rehabilitation) gives the most well-rounded and optimal results for your patients with Cervicogenic Dizziness.


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.

Sign up for more emails on this topic by clicking here

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

 

What is BPPV and what factors lead up to having this diagnosis?

Cervicogenic Dizziness, Cervical Vertigo

Cervicogenic Dizziness, Cervical Vertigo, Neck Pain, Dizziness, Cervical Spine

Benign paroxysmal positional vertigo (BPPV) can be defined as transient, position-induced torsional, vertical, or horizontal nystagmus with vertigo.

What causes BPPV?

The pathology is based on displacement of the otoconia in the semicircular canal (canalolithiasis) or attachment of debris/otoliths to the cupula (cupulolithiasis). It can be a primary issue or secondary issue from other conditions.

Unfortunately, the underlying pathology is often obscure and the “main” reason is not always known – hence, what we call idiopathic. In this case, we call it idiopathic BPPV.

What factors lead up to having this diagnosis?

Considering most cases of BPPV are idiopathic, there are other factors associated with BPPV. Everyone wants to know “why” they have this diagnosis and as healthcare professionals, we can’t always pinpoint one specific reason. But, usually there are several reasons that then “overload” your system and cause a “spill-over” effect —- which means your body can’t compensate any further and you get symptoms.

Here is a list of 18, yes 18, factors associated with BPPV!

  1. Aging

  2. Migraine

  3. Meniere’s Disease

  4. Trauma (such as car accident, concussion, whiplash)

  5. Infection

  6. Vestibular Neuronitis

  7. Idiopathic sudden sensorineural hearing loss

  8. Sleeping habits

  9. Osteoporosis and vitamin D insufficiency

  10. Hyperglycemia and diabetes mellitus

  11. Chronic head and neck pain

  12. Vestibule or semicircular canal pathology

  13. Pigmentation disorders

  14. Estrogen deficiency

  15. Neurological disorders

  16. Auto- immune, inflammatory, or rheumatologic disorders

  17. Familial or genetic predisposition

  18. Allergy

Wow, that’s a lot of factors that could lead to you having BPPV!

What does all of this mean for me if I treat BPPV and even other dizzy/vertigo patients?

Vestibular Therapy to Treat Cervicogenic Dizziness

Basically, this means that the well-rounded treatment is more than just “a manuever”. Yes, we can all knock this out and do a pretty solid job with it!  It is the more “complicated” cases that we aim for and can help the most.

Overall, we recommend getting trained in Vestibular Rehabilitation and Upper Quarter Manual Therapy to fully address these patients.  Also, take the time and training to examine their symptoms and discuss lifestyle factors and other strategies to not only prevent BPPV from having again but overall, address the entire body and give it all to your patients.

How does BPPV relate to Cervicogenic Dizziness?

For this article and our specialization under the realm of Cervicogenic Dizziness from Cervical Arthrogenic and Myofascial pain, I like to address 2 of the 18 points above — numbers 4 and 11.

#4 Trauma (such as car accident, concussion, whiplash)

We consider someone who has had trauma under the realm of “double entity”.  This means that there are at least 2 systems involved (i.e. inner ear and neck pain).  This is more common than generally Cervicogenic Dizziness is identified in the literature and quite frankly, we find some type of neck disturbance in pretty much every single one of these patients.

#11 Chronic head and neck pain

This coincides well with Trauma above but may need more explaining to the patient as there is not one single type of injury.  This is what you can consider to be more of a single entity instead of just BPPV, but coincides in at least 70% of our BPPV patients.  As we discuss in our clinic and courses, we recommend treating BPPV first via canalith repositioning manuevers, but adjunct it with manual therapies and exercises for the neck to fully treat the whole system.


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 addressing the articular and non-articular dysfunctions of the neck; as well as graded exercise, vestibular and sensorimotor approaches. 

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

Can True Vertigo be a Symptom of Cervicogenic Dizziness?

Cervicogenic Dizziness, Cervical Vertigo

The term vertigo refers to the illusion of environmental motion, classically described as “spinning” or “whirling.” The sense of motion is usually rotatory—”like getting off a merry-go-round”—but it may be more linear—”the ground tilts up and down, like being on a boat at sea.” (Reilly B 1990). Vertigo is defined as the subjective perception of rotational or translational movement in the absence of an external stimulus (You et al 2019).

Generally speaking, vertigo reflects a dysfunction in the vestibular system.  Among patients with vertigo, benign positional vertigo is most common and is diagnosed up to 42% of the time with vertiginous symptoms. It is a common clinical disorder characterized by brief recurrent spells of vertigo often brought about by certain head position changes as may occur with looking up, turning over in bed, or straightening up after bending over. Recently confirmed, vertiginous attacks by turning or laying down in bed together with dizziness <1 minute, are important questions and strongly related to BPPV (Lindell et al 2018).

Using the word “bed” and “spinning sensation” during symptoms description are a common finding in someone with BPPV.  Historically speaking, this is not as common in a patient describing symptoms of Cervicogenic Dizziness.  The lack of true vertigo as a symptom of Cervicogenic Dizziness goes back to Brandt & Bronstein’s work in 1996 and not in typical descriptors from Wrisley’s work in 2000. 

L’Heureux-Lebeau et al 2014 differentiated patients having Cervicogenic Dizziness vs BPPV and showed differences in sensorimotor disturbances between the two groups.  Patients with Cervicogenic Dizziness were found to have a sensation of drunkenness and lightheadedness. Patients with BPPV more frequently mentioned rotatory sensation, which is not typical of cervicogenic dizziness.

Cervicogenic Dizziness, Cervical Vertigo, Neck Dizziness

With this being said, it is interesting to note the findings of a more recent study by Thompson-Harvey & Hain in 2019.  The authors formulated a 41-question survey to identify patient features distinguishing cervical vertigo from vestibular causes of vertigo and vestibular migraine.  They found that twenty-seven (27%) of cervical vertigo subjects complained of vertigo – i.e. spinning sensations. This is contrary to the work of Brandt & L’Heureux-Lebeau, as well as most practicing clinicians in the vestibular field; including ourselves.  1 in 4 patients diagnosed with cervical vertigo had actual vertigo symptoms!

They found that twenty-seven (27%) of cervical vertigo subjects complained of vertigo – i.e. spinning sensations.

1 in 4 patients diagnosed with cervical vertigo had actual vertigo symptoms!

Even though L’Heureux-Lebeau et al 2014 found that patients with Cervicogenic Dizziness were found to have a sensation of drunkenness and lightheadedness vs BPPV patients noting more rotatory sensations, if you dive into the paper, you will find that 32% (1 in 3!) patients with Cervicogenic Dizziness actually described their symptoms as rotatory sensation too!

1 in 3 (32%) of patients with Cervicogenic Dizziness described their symptoms as rotatory sensations!

Furthermore, Thompson-Harvey & Hain found that the frequency of symptoms elicited by “turning over in bed” was almost identical across groups (cervical vertigo, migraine and vestibular vertigo).  As the authors denote, the symptoms endorsed by subjects with cervical vertigo overlap substantially with well-established vestibular disturbances and migraine.

Therefore, even though I would still suggest that true vertigo is not a common descriptor of Cervicogenic Dizziness, as a clinician, I definitely would not rule out this condition if a patient has this symptom.  From the research indicated above that, to date, is the only studies comparing dizziness from cervical origin to peripheral origin, indicate between 1 in 3 to 1 in 4 of your patients will have rotatory sensations (i.e. vertigo).

I do feel this continues to demonstrate an overlap of symptoms and systems in very complex  head on neck disorientation conditions.  It also continues to demonstrate the the “vestibular clinician” should be able to effectively and confidently assess and treat the cervical spine.


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.

Sign up for more emails on this topic by clicking here

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

2 Mistakes You Could Make with Cervicogenic Dizziness Diagnosis

Cervicogenic Dizziness, Cervical Vertigo

Cervicogenic Dizziness, Cervical Vertigo,

The diagnosis of Cervicogenic Dizziness is one of exclusion.  What this means is that the clinician should make sound reasoning to rule out other conditions that could be causing dizziness.  We created our own algorithm, which we call the “Optimal Sequence Algorithm” to help clinicians come up with appropriate clinical decision making.

The main reason of this “exclusion rule”, is that dizziness is a red flag!  It could be a benign condition or a symptom of a very serious underlying disorder.

With that said, the two most common conditions that are mistaken for Cervicogenic Dizziness is Benign paroxysmal positional vertigo (BPPV) and a vascular insult, such as vertebral basilar insufficiency (VBI) or collectively known as Cervical Artery Dysfunction (CADF).

Cervicogenic Dizziness

The main reason we need to be aware of these two conditions is simple:

  1. BPPV is benign — a non-life threatening condition.  It can be treated by a rehabilitation professional, such as a physical therapist.
  2. VBI and CADF — a life-threatening condition.  It should not be treated by a rehabilitation professional, such as a physical therapist, initially.  It should be direct route to other medical examinations and hopefully just pharmacological intervention before anything worse happens.

Cervicogenic Dizziness is also a non-life threatening condition.  Therefore, a clinician who sees someone with dizziness, headache, lightheadiness, drunkenness, unsteadiness, loss of balance, etc. should absolutely have a foundation of ruling out spontaneous arterial events and then mechanical arterial events prior to examining the cervical spine’s joint and muscle mobility & performance.


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.

Sign up for more emails on this topic by clicking here

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

This is why Vestibular Therapists should learn Manual Therapy

Cervicogenic Dizziness, Cervical Vertigo

It is well known that vestibular rehabilitation is an effective program for many patient profiles that can walk into a physical therapist office.  A well-planned and adjusted program based off of symptoms is the basis behind strategies to improve Chronic Unilateral Vestibular Hypofunctions, Bilateral Vestibular Hypofunctions, mTBI and post-concussion syndrome.

Cervicogenic Dizziness, Cervical Vertigo, Neck Dizziness

It can be individualized through a tailored, progressive program to the patient for effective outcomes. Improvement is typically gradual as the system adapts and includes a home exercise program.

Classical signs and symptoms of vestibular dysfunction that would warrant vestibular rehabilitation include dizziness, vertigo, disequilibrium, nausea, and visual impairment.  With the ongoing scientific research showing neurological connections via several reflexes and mismatch theories of afferent information, a healthcare provider should also consider vestibular rehabilitation for chronic neck pain.

Cervicogenic Dizziness, Cervical Vertigo, Neck Dizziness

In fact, I would bet majority of the patients whom are seeking out vestibular rehabilitation has either cervical pain and/or limitations in cervical function (i.e. altered active/passive range of motion, strength and endurance of deep cervical flexors/extensor, cervical kinesthetic sensibility, greater joint position error, pressure pain sensitivity).

Not just me making this comment, but Knapstad and colleagues in 2019 made the following conclusion in a cross-sectional study in Disability and Rehabilitation Journal:

Neck pain was equally prevalent in patients diagnosed with dizziness of vestibular and non-vestibular origin. This indicates that neck pain is a common complaint in dizzy patients regardless of diagnosis.

Additionally, Thompson-Harvey & Hain in 2019 documented that symptoms endorsed by subjects with cervical vertigo, migraine, and vestibular vertigo overlap.  Therefore, neck limitations, due to pain, stiffness or even abnormal imaging findings with both local neck origin, as well as a double entity of vestibular or central origin, can manifest an exaggerated proprioceptive response and translation into subjective symptoms of dizziness, lightheadiness and imbalance.

The basis behind Cervicogenic Dizziness treatments is that the patient has dizziness originating from the cervical spine, but couldn’t it be plausible that the dizziness could be coming from another source (i.e. peripheral) but compensatory strategies over time make it appropriate and quite reasonable to also address changes in the cervical spine due to altered head on neck orientation?

The basis behind mechanisms of manual therapy has been changed away from just local, biomechanical changes to the tissues to a more complex peripheral and central mechanisms.  Majority of the clinical effects are now known to be neurophysiological in nature.  Therefore, considering these patients have a head on neck disorientation that does warrant vestibular rehabilitation, could we get faster results, more buy in and ease of any nocioception that may hinder clinical outcomes.Cervicogenic Dizziness, Cervical Vertigo, Neck Dizziness

I like this quote from a 2018 study by Daniel García-Pérez-Juana, et al :

It is plausible that manual therapies can immediately enhance proprioception and may be a reasonable treatment approach to prepare a patient for exercise interventions.

The study quoted above examined Cervicocephalic Kiniesthetic Sensibility, Widespread Pressure Pain Sensitivity and Neck pain following spinal manipulation to the cervical spine.  Even if you do not believe in spinal manipulation or do not feel comfortable performing it on patients, it is wise to seek out some type of manual therapies that focus on high content from the muscle spindle and proprioceptive areas that is time-efficient, straightforward and effective.

This is why our Physio Blend incorporates your past knowledge and skill set with manual therapies without providing such “systems” as if you would feel like you need to learn before application.  Our Physio Blend for Cervicogenic Dizziness includes both joint and soft tissue/muscle manual intervention.  And trust us, treating the neck is MUCH more than prescribing ROM and upper trapezius stretching. 

So even if your patient is not having neck pain (so therefore, may not actually be able to be classified as Cervicogenic Dizziness), a vestibular/neuro therapist should consider manual therapies to the cervical spine due to its effects on proprioception, pain and cervical kinaesthetic sense.

I’ll end this post with another quote from Knapstead in 2019:

The relationship between neck pain, general and dizziness-related quality of life should make medical practitioners aware of these patients regardless of whether or not a vestibular disorder has been diagnosed.


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 do you treat Cervicogenic Dizziness?

Cervicogenic Dizziness, Cervical Vertigo

Cervicogenic Dizziness, Cervical Vertigo,

How do you treat Cervicogenic Dizziness?

In order to provide the most appropriate treatment, you need to figure out the most appropriate diagnosis.  Examining proper symptoms and ruling out other conditions that could contribute to dizziness and lightheadiness is the first course of action for someone you are considering to have Cervicogenic Dizziness.

From there, there are many options to treat the patient and this could be determined on what type of clinician you see.

Acupuncturist: you will get acupuncture

Chiropractor: you will get chiropractic manipulation (other procedures probably as well…)

Massage therapist: massage

Physical Therapist: well…depends on who and where.  Read more below.

For a clinician who is a vestibular therapist with minimal manual training, you will most likely get mostly vestibular therapy and some manual therapy to the neck. For the manual therapist with minimal vestibular training, you will most likely get the opposite — more manual therapy to the neck and less vestibular therapy.

Manual Therapy to the Neck for Cervicogenic Dizziness Treatment

Honestly, for the most appropriate treatment of Cervicogenic Dizziness — the procedures all depends on the clinical findings.  We can make a grand statement based on the research that acupuncture (as of this blog writing in Dec 2019) has the only meta-analysis (top dog evidence) for Cervicogenic Dizziness where you will find more randomized control-trials in the physical therapy literature, specifically using Mulligan or Maitland therapeutic approach.

Vestibular Therapy to Treat Cervicogenic Dizziness

We teach in our course to examine all systems and address them in the most proper way based on your skill set and patient’s presentation.  We are on a mission to combine both manual and vestibular therapies to help patients who may be referred to an outpatient clinic, vestibular clinic, sports clinic, pediatric clinic or even neurological clinic!

Example of Cervical Motor Control treatment for Cervicogenic Dizziness

We teach our students what the literature says in regards to the best available evidence but what I really like to do is “blend” procedures together.  We really shouldn’t separate the procedures and evidence of effectiveness between vestibular and manual therapy.  To describe this “marriage”, we call this the “Physio Blend”.  

I do find that there is usually a combination of vestibular and orthopedic findings and if only addressing one without the other, then you are doing a disservice to the patient.

It is like treating someone with knee pain by only performing procedures on the hip and not the ankle!

There you go!  This is the exact formula and clear message of how to treat Cervicogenic Dizziness 🙂


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 second day provides the most up-to-date evidence review from multiple disciplines to treat through the “Physio Blend” to combine the specialities of manual therapy, vestibular therapy and sensorimotor training.  

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.

Sign up for more emails on this topic by clicking here

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

You are 30 times more likely to improve dizziness by doing it this way

Cervicogenic Dizziness, Cervical Vertigo

Cervicogenic Dizziness, Cervical Vertigo, Neck Pain, Dizziness, Cervical Spine

It is without a doubt that treating a multi-system symptom of dizziness is challenging!  Not only can dizziness be a vague phrase for similar descriptions such as vertigo, lightheadiness, unsteadiness or even drunkenness, it is hard to “capture” objectively.

Cervicogenic Dizziness, Cervical Vertigo, Neck Dizziness

Vestibular rehabilitation principles that have been present since mid-1940s is by far one of the best ways to rehabilitate dizziness from vestibular lesions.  Prior to these approaches, the treatment of dizziness was usually wait-and-see, medication and/or manual therapies (i.e. chiropractic, acupuncture, osteopath — as physio didn’t really have much manual therapy at this time).

In the last half-decade, the understanding of correlating manual therapy and vestibular principles has yielded to be superior in the treatment of double entities (also known as double origin).  We are now seeing a trend towards a third pillar of rehabilitation for some dizziness disorders, called proprioceptive cervical training.

To bring this to real-life circumstances, I take you to the recent retrospective review by Hammerle et al in 2019.   In short, the study aimed to assess the outcomes of 2 treatments for patients with dizziness after mild traumatic brain injury (mTBI) who demonstrate abnormal cervical spine proprioception — vestibular rehabilitation or cervical spine proprioceptive re-training (CSPR) — alongside their facility’s standard manual therapy approach.

Here are some of the major results:

“The logistic regression analysis indicated treatment as a significant predictor of dizziness improvement, indicating that those who received the CSPR treatment were approximately 30 times more likely to report improved dizziness relative to those who received usual care.”

Cervicogenic Dizziness, Cervical Vertigo

85% of the individuals in the CSPR group and only 18% in the usual care group had dizziness improvement

The authors go on to state:

These findings suggest that treatment directed toward cervical proprioception may be important for individuals with dizziness after mTBIwhere signs of altered CSP are demonstrated and no clear peripheral vestibular or consistent central signs are present.

Furthermore, here is the direct conclusion:

“The study results demonstrated that active-duty military patients after mTBI with dizziness, abnormal CSP tests, no active vestibular pathology, and no consistent central signs who had treatment directed toward CSP seem to improve in their dizziness symptoms more than the patients who had the usual care (consisting of VRT). “

If you are looking to find the most consistent blend of manual therapy, vestibular and sensorimotor training; we offer our systematic approach based off of evidence as you just read with the art of therapeutic planning and progression with not just your mTBI patients, but also neck pain and vestibular dysfunctions.


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

Presbypropria: I bet you don’t know what this means

Cervicogenic Dizziness, Cervical Vertigo

A common term that is thrown around in the physical therapy and rehabilitation conversations in graduate school PT labs and clinics is proprioception.

Derived almost 120 years ago by Sherrington, the term proprioception — from Latin proprius (own) and recipere (recept) — encompasses both the senses of limb movement (kinaesthesia) and limb position (joint position sense or stataesthesia).

Proprioception can be used in training programs to prevent injuries and in rehabilitation program to alleviate injuries and get a patient back on the court, walking down a sidewalk, etc.  We know proprioception declines as we age and one, of many, reasons why there is a higher fall risk.

Just as our eyes aren’t as good as we get older and our vestibular sense declines; our joints and muscle spindles have impaired afferent input.  Several of these systems (i.e. peripheral) alongside altered cortical compensation and integration systems (i.e. central) results in a proprioceptive deficits.

Impaired proprioception in physiological ageing (peripheral and central) can explain the impaired proprioception observed in older adults.

For our geriatric rehabilitation, we tend to address several systems associated with fall risk, such as strength, flexibility, ROM, vestibular rehabilitation.  However, one aspect of geriatric rehabilitation that I think is lacking is addressing main generators of proprioception in our bodies: upper cervical joints and muscle spindles.

We know the dysfunctional afferent information from these structures can impair balance, postural stability and mobility of the cervical spine, hence, hindering head on neck orientation, spatial awareness and kinesthesia.

I am not stating this has to be addressed just manually, which I think is inferior treatment, but to start off with manual therapies to make quicker changes in the afferent input and then progress to sensorimotor, vestibular and/or strengthening to this region to address impairments found in clinical assessment.  I feel a combined proprioceptive task addressing all of the impaired systems and leads to more accurate and consistent results.

Cervicogenic Dizziness, Cervical Vertigo

During our classes, I encourage our amazing participants to try some of the techniques and methods that we utilize to alleviate dizziness on general, geriatric population with balance disorders.  I encourage you to try the same and see what type of results you get!

Oh…Back to Presbypropria

The word “presbypropria”, as the prefix presby comes from Greek presbus (old).

The word “presbypropria” could be appropriate to name the alterations of older adults’ proprioception.

We could even add cervical to the mix and promote our own approach to manage “Cervical Presbypropria”.

Next time you’re out with your colleagues, toss out presbyropria.  Now that’s fresh.


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

What are symptoms of Cervicogenic Dizziness?

Cervicogenic Dizziness, Cervical Vertigo

Cervicogenic Dizziness, Cervical Vertigo,

What are symptoms of Cervicogenic Dizziness?

The symptoms of Cervicogenic Dizziness can vary.  This is due to the vague definition of Cervicogenic Dizziness and the confusing aspect that Cervicogenic Dizziness is still called Cervical Vertigo.  This leads us to the symptoms…

Cervicogenic Dizziness is not described as true vertigo.  If it is, this is very rare.  Vertigo is defined more as the room or the person is spinning.  That would lead someone to think more of a diagnosis such as BPPV (with the V meaning for Vertigo).

Therefore, Cervicogenic Dizziness would not be described as room or person spinning, or true vertigo.  The following are other descriptors and symptoms that are typical from a patient with this condition:

  • Dizziness
  • Lightheadiness
  • Unsteadiness
  • Drunkenness

Other descriptors could be:

  • I feel like I may fall
  • People tell me that my head is not on straight
  • I can’t walk straight

Additionally, patients may also have symptoms of:

  • Neck Pain
  • Tightness in neck and shoulders
  • Headache

There you go!  Nice and generalized descriptors of symptoms — but isn’t this normal for conditions, especially ones involving the vestibular and musculoskeletal system!


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.

Sign up for more emails on this topic by clicking here

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

What is Cervicogenic Dizziness?

Cervicogenic Dizziness, Cervical Vertigo

Cervicogenic Dizziness, Cervical Vertigo,

 

What is Cervicogenic dizziness?

Cervicogenic Dizziness, or also known as Cervical Vertigo, can have many definitions.  In fact, we provide all of the various definitions noted in the research in our Cervicogenic Dizziness Course.  We bring this topic up in our introduction to explain to clinicians that they will see a ton of different definitions out there!

The definitions vary from each discipline, including the physical therapists, neurosurgeons, and acupuncturists.  It can be confusing!

Nevertheless, here are 3 of the top used definitions:

  1. Illusory motion deriving from a disturbance in the neck
  2. A non-specific sensation of altered orientation in space and disequilibrium originating from abnormal afferent activity from the neck.
  3. Non-rotary dizziness is described as imbalance or unsteadiness and is related to movements or positions of the neck.

What you will find in any modern definition of Cervicogenic Dizziness is that there is a temporal relationship between the symptoms and neck movements, pain or physical findings.  The latter part of the definition is still vague as I would suggest you can still have Cervicogenic Dizziness even if you do not have “pain”.

Why?  Well, that is a longer conversation and for a future post.


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.

Sign up for more emails on this topic by clicking here

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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