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

Can your patient have dizziness 10 years after neck surgery?

Cervicogenic Dizziness, Cervical Vertigo

What if I told you that 7 out of 10 of your patients who had an anterior cervical disc fusion (ACDF) had occasional or daily dizziness and/or unsteadiness 10 years later!?

One of the biggest arguments against Dizziness from Cervical Origin (i.e. Cervicogenic Dizziness) is a consistent lack of agreement between professionals of the neck as a driver of symptoms.  Generally speaking, manual based professionals such as acupuncturists, chiropractors and physical therapist hoot “yes” while ENTs and otoneurologists yelp “no”.  This exact topic was one of our most common posts and can be found here.

Nevertheless, we are seeing more and more evidence come out in the last few years in the literature showing correlations between neck disorders and balance/dizziness.  The kicker — this work is done by surgeons.  We wrote on this exact topic a few months ago too and can be found here.

In early 2019, Hermansen A et al performed a cross-sectional study with 10–13-year follow-up using self-reported data on dizziness and balance problems in patients who previously received an anterior cervical fusion (ACDF).  Here is what the authors found:

Highlights

  • Pain was significantly associated with dizziness, but not balance.
  • Health-related quality of life correlated to symptoms.
  • Seventy-two percent experienced occasional or daily symptoms of unsteadiness and/or dizziness.
  • There was a moderate correlation with dizziness during movement and balance problems.
  • The patients’ symptoms of dizziness or balance problems had impact on daily life according to the Dizziness Handicap Inventory.
    • Twenty-one (31%) individuals had moderate, and six (9%) had severe disability.
  • The quality of dizziness was described by 12 individuals as non-rotatory, a vague feeling of discomfort, a sensation of lightheadedness, or imbalance/postural unsteadiness.

Neck pain, reduced neck-muscle endurance, and reduced neck range of motion (mobility) are impairments seen in patients after ACDF.  Therefore, it is not surprising to see these type of results.  What is surprising, at least in the fact that I have never seen it “on paper”, is the percentage (72%) of patients still experiencing these type of symptoms a decade later!

Other Take-aways

  • These patients had surgery (ACDF) for cervical radiculopathy and not for any dizziness symptoms.  I wonder how many had symptoms prior to surgery.
  • This data also confirms that these type of symptoms can have an origin from the cervical spine further placing proof that this area can be at fault.

If you are a currently rehabilitating patients s/p ACDF or other cervical surgery, it is pertinent to continue to address pain but also examine balance and sensorimotor disturbances.  I recommend we, as rehabilitation professionals, address these impairments early in the rehabilitation stage and even have an open conversation with the patient about potential future symptoms of unsteadiness/dizziness.  It could definitely lead to the patient returning to you for treatment in the future and if treated appropriately, improve overall quality of life.


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 time of the year is BPPV more prevalent?

Cervicogenic Dizziness, Cervical Vertigo

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

A recent study by Korpon et al 2019 in Am J Otolaryngol examined barometric pressure and the incidence of benign paroxysmal positional vertigo (BPPV).  The aim of this study was to determine the temporal relationship between monthly barometric pressure levels and incidence of BPPV.

The following is what the authors found:

Of all the variables studied (compared to temperature, humidity, tree/mold/grass/ragweed pollen), barometric pressure demonstrates the strongest statistically significant positive correlation, where every one unit increase in barometric pressure leads to an expected increase of 6.1 diagnoses (r = 0.66 [95% CI 0.14–0.90], p = 0.0131).

BPPV diagnoses were observed to be lowest during the summer months (June through August) with a moderate to strong, statistically significant positive correlation between BPPV diagnoses and barometric pressure observed throughout the year.

Therefore, as a clinician, you may find that BPPV diagnosis occur more often in the first of the year (say January – May), which, from this study, is most likely related to barometric pressure (compared to sunlight levels, pollen, etc).

As clinicians, what time of the year do you find BPPV to be more prevalent?

As patients, what time of the year does your BPPV “flare up”?

The authors go on to discuss correlation between BPPV and migraine, which do correlate with barometric pressure.  Recently, pain and barometric pressure has just been shown to be related on an individual level (Fagerlund et al 2019). Even though the research is not strong with correlations of the weather, I would ask your patients what they think!  Most do!

We notice in clinical practice that a certain percentage of patients who have BPPV have a double-entity of cervical impairments too.  This can be as simple as guarding and hypertonicity of the cervical muscles due to avoidance of movements or underlying joint hypomobility and muscular impairments (strength, endurance, etc) that place the proprioceptive system at half capacity.

We do not have a ton of data on prevalence or incidence of persons having Cervicogenic Dizziness besides post-trauma (whiplash, car accident, concussion, sport injury, etc).  However, we can take the above information and relate it to what we already know about time of year and barometric pressure to make correlations between ion channel sensitivity and its affect on Cervicogenic Dizziness.

Considering persons with Cervicogenic Dizziness typically have neck pain & Yacovino and Hain in 2013 determined a 4th pathophysiology for Cervicogenic Dizziness (vestibular migraine), you could potentially see a higher incidence of Cervicogenic Dizziness during the months of January – May as well.  We do not have all of the answers to the association but could be based on pathophysiology of the tissues (such as in headaches, osteoarthritis or inner ear disorders) or affective states (i.e. psychosocial emotional status).  Considering there is conflicting research findings on the associations, we do not fully understand the phenomena.


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

You can save yourself $400 by testing cervical ROM this way!

Cervicogenic Dizziness, Cervical Vertigo

Abnormal cervical range of motion (ROM) has been used as part of the clinical decision making for the diagnosis of Cervicogenic Dizziness.  The limitation in range of motion, as well as pain to palpation to upper cervical spinal structures, can help the clinician differentiate between dizziness of vestibular origin vs cervical origin.

I am classically more of an “eye-ball” kind of ROM guy but continuing to look for objective ways to assess cervical dysfunction to not only prove a difference to the patient, but also for goal setting.

Currently the gold standard and most objective way to clinically measure the ROM is the CROM device (Cervical Range of Movement).  I was part of a study about a decade ago and used the device, but it is expensive (upwards to $400) and potentially necessary in a clinical environment.   Plus — its ugly and patients feel weird with it on!  I mean — she doesn’t look too happy does she 🙂

Credit: Fabrication Enterprises PA CROM

Cervical ROM is common in clinical assessment to examine individuals with pain.  Nothing has really changed in the procedure for decades. However, the use of smartphone applications to measure ROM is gaining popularity.  Considering majority, if not all, therapists have the phone handy throughout a session, it is time to utilize the technology.

I have found that patients perceive the phone technology as a higher value in clinical assessment, which could potentially place higher value on your overall treatments.  This is anecdotal evidence but also seeing this more with applications to assess posture, running mechanics, etc that is more feasible in clinical practice vs laboratory settings.   However, even with higher perceived value, we need to make sure the technology holds up to our gold standard—the CROM. 

**Back story—I was part of an initial project about 10 years ago comparing different applications in a ceased website—therefore, have had the interest in other ways to measure ROM for years.  The evidence out now of reliability and validity was not available back then**

A recent study by Rodriguez-Sanz et al 2018 examined two smartphone applications (Clinometer & Compass) against CROM for individuals with chronic pain and found:

Cervicogenic Dizziness, Cervical Vertigo, Neck Pain, Proprioception
Courtesy: Rodriguez-Sanz J et al 2018
  • Excellent validity (>0.75) of lower and upper cervical spine movements
  • Excellent intra-rater reliability (>0.75) of lower cervical spine movements
  • Excellent inter-rater reliability (>0.75) of lower cervical spine movements
  • Excellent intra- and inter-rater reliability of upper cervical spine extension movements
  • Good intra-rater reliability (0.65-0.75) of upper cervical spine flexion movements
Cervicogenic Dizziness, Cervical Vertigo, Neck Pain, Proprioception
Courtesy: Rodriguez-Sanz J et al 2018

In conclusion, the Smartphone applications “Clinometer” and “Compass” have been proved of an excellent validity, by using CROM as gold standard in the lower cervical spine and upper cervical spine ROM measurements in subjects with 441 chronic cervical pain.

Based off of this study alone, I would feel confident as a clinician to use these applications to measure cervical AROM of the upper and lower cervical spine and knowing it will have solid validity and reliability against our gold standard, the CROM device.

Granted, the patients in this study were considered to have “chronic cervical pain”— which meant over the age of 18 and pain in cervical region for > 3 months.   This hasn’t been studied specifically with patients with Cervicogenic Dizziness, but could be highly relevant as these patients have limitations in cervical ROM, especially cervical extension and rotation.

Now rock on smart phones!

Rock on more to save $400 for purchasing a CROM device in your clinic!


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

Vestibular Nucleus: The Eye of the Hurricane

Cervicogenic Dizziness, Cervical Vertigo

Regular practice of exercises that connect the mind and body, such as Tai Chi and Yoga, aid in teaching you how to focus.  In our modern world, this means mindfulness.

A key phrase that is often taught for focus is,

Move from the eye of the hurricane and not be swept away in the surrounding confusion

So, how does this relate to Cervicogenic Dizziness?!

This reminds me of an ever-so-important “eye” of the surrounding storm in the complicated and perplexing area of dizziness, lightheadiness and vertigo ==>>the vestibular nuclei.

The vestibular nuclei are important centers of integration, receiving input from the vestibular nuclei of the opposite side, as well as from the cerebellum and the visual and somatic sensory systems (Purves et al 2001).

Cervicogenic Dizziness, Cervical Vertigo,

Neurons in the vestibular nucleus, which receive direct inputs from the vestibular afferents, ocular afferents, cervical afferents and several other locations as shown in diagram above are responsive to head velocity during passive whole-body rotations or passive head-on-body movements.

Therefore, if a mismatch of signals in the “storm” of the hurricane (i.e. several afferent sources); then the ultimate symptom can be vague description of dizziness and vertigo.

Vestibular nuclei neurons are responsive to passive neck proprioceptor activation.  Considering a high percentage of proprioception is in the muscles spindles and joint capsules of the upper cervical spine, this can be a cause of the patient’s symptoms.

The sensorimotor control disturbances may result from either a decrease or an increase in cervical afferent activity. The crucial factor appears to be that afferent input is altered and abnormal.  For these individuals, the ultimate symptom can be vague description of lightheadiness, unsteadiness and dizziness.

The Perpetual Cycle of Incorrect Afferent Information Input is known as Sensory or Neural Mismatch Concept. 

Therefore, think of the Vestibular Nucleus being in the “Eye of the Storm” needing to focus even with the turmoil sweeping around it.

Cervicogenic Dizziness, Cervical Vertigo, Proprioception, Neck, Dizziness, BPPV
Cervicogenic Dizziness

Our job is to figure out where this turmoil is coming from and if it is solely cervical dysfunction or cervical dysfunction in combination with other wacky information, then to figure out how to most effectively help the patient in regards to manual therapy, sensorimotor exercise, and vestibular rehabilitation. 


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

We REALLY need this study to favor physical therapy over surgery

Cervicogenic Dizziness, Cervical Vertigo

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

Ahhh, in the conservative rehabilitation field, we do not like seeing positive results from surgery studies!

Just being honest with that statement, but, at times, some individuals are very appropriate for surgical procedures.  Most surgeons (and of course insurance companies now) will even say surgery is not first-line approach, especially for Cervicogenic Dizziness.  We have actually written on this topic before in a previous post that you can find here.

In 2019, Li et al assessed the clinical outcomes of patients with cervical vertigo who failed to improve with conservative care and who were subsequently treated with percutaneous disc decompression with coblation nucleoplasty (PDCN).  To my knowledge, this is the first long term study showing outcomes of surgery (minimally invasive) for the treatment of Cervicogenic Dizziness or Cervical Vertigo.

Photo: Li et al 2019

The point of this post is not to assess the details and and approach of this procedure for Cervical Vertigo, but to mainly speak about the last statement the authors wrote in the discussion session:

We are thus going to carry out a prospective RCT comparing PDCN with manual therapy to confirm the effectiveness of PDCN in cervical vertigo.

The biggest takeaway: we want physical therapy with manual therapy (conservative care) to be more effective or just as effective as surgery (even minimally invasive) in treatment of Cervicogenic Dizziness or Cervical Vertigo.  A prospective RCT is high level evidence and if the results go the other way, it gives precedence in lighting the fire of more surgery procedures as treatment for this condition.  Of course, this would be even worse for our industry if the study is a long-term (at least 1 year) follow-up.

In the physical therapy and rehabilitation research, we have two long term follow-up studies.  One by Susan Reid and her colleagues in 2015 and from Malmstrom et al in 2007.  Otherwise, at least at the time of this writing, we don’t have the juice or thick substance in making our argument of solely conservative measures of manual physical therapy for treatment of Cervicogenic Dizziness.

Pondering thoughts — let’s continue to give a big fist bump for our researchers and scientists who are making strides in better research on this condition. I have to say I haven’t published on this topic even though we teach it.  I rely heavily on our academicians in our industry to help me out make my argument.

One thing I alluded to in the video is the limitation behind RCTs.  Biggest one I run across clinically is lack of multiple procedures that are usually necessary for more complicated cases, such as in cases that led to surgery in the Li study.  That is why we teach not only several types of manual therapies throughout the cervical spine, but this in combination of pain-reliving exercises, motor control exercises, vestibular and sensorimotor approaches.  Dizziness alongside cervical pain is unlike headaches, which do not normally have multiple dysfunctional afferent input from the vestibular, visual AND sensorimotor (i.e. proprioception from the neck) systems.  Therefore, it is pertinent that the clinician knows how to effectively treat these systems in order to most effectively treat Cervicogenic Dizziness.

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

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

 

Importance of deep cervical extensor muscles in Cervicogenic Dizziness

Cervicogenic Dizziness, Cervical Vertigo

Individuals who have dizziness from cervical origin typically have several general symptoms, including neck pain, balance impairment including unsteadiness, lightheadiness and drunkeness.   Types of patients with this condition range from the elderly with cervical arthritis (slow onset of symptoms) to status-post mild traumatic brain injury (mTBI) following a concussion or whiplash (fast onset of symptoms).Cervicogenic Dizziness, Cervical Vertigo,

For the purpose of this post, we will examine the importance of cervical extensors in Cervicogenic Dizziness. Considering head extension is a primary impairment for onset of symptoms in the Cervicogenic Dizziness population, this is a significant area of interest.

The suboccipital musculature is central to promoting and resisting head motion.  These motions include flexion, extension, and rotation. The suboccipital musculature associated with cervical extension are the rectus capitis posterior major (rectus capitis-PMaj), rectus capitis posterior minor (rectus capitis-PMin), and obliquees capitis inferior (OCI).  Additional cervical extensors are the semispinalis cervicis, multifidus, semispinal capitis, and splenius capitis.

Cross-section of suboccipital musculature.
Photo courtesy of:
Fahkran et al 2016.

Previously, it has been found that atrophy of the suboccipital muscles is associated with chronic neck pain (Andary et al). In fact, greater atrophy in the rectus capitis-PMaj and rectus capitis-PMin among the suboccipital muscles have been found in patients with persistent whiplash symptoms (Elliot et al) Additionally, atrophy of these muscles has been associated with higher inflammatory biomarkers, hyperalgesia, and worse outcomes in patients with whiplash (Sterling et al)

Furthermore, rectus capitis-PMin has been associated with greater symptomatology, poorer outcome, and posttraumatic headaches after mild TBI (Fakhran et al). Additionally, atrophy of the suboccipital muscles following whiplash is involved in marked, chronic neck pain and reduced standing balance (McPartland et al).

RCPmi dissection.
Photo courtesy of Yuan et al 2017

Even though most research conducted with the rectus capitis-PMin correlates this muscle with the myodural bridge and association with cervical headaches, we believe there is a paucity of research analyzing this area in regards to Cervicogenic Dizziness and complex dizziness symptoms.

The rectus capitis-PMin has the greatest concentration of muscle spindles among the suboccipital musculature, which, in addition to allowing flexible movement, act as specific sensory receptors.  This role is accomplished secondary to an especially high concentration of large diameter A- fibers, which convey proprioceptive information.

Even though we may not be able to prevent onset of mTBI, concussion, whiplash symptoms with strengthening the deep cervical extensors, we can certainly utilize this knowledge in our rehabilitation setting.

Or, we could even look at this at another angle and potentially utilize this knowledge in fall prevention programs to address coordinated afferent input from the cervical spine to the balance centers.  As far as we know, there is some literature on manual therapies (such as Holt et al 2016 & Doughtery et al 2012) to improve balance in elderly but to our knowledge, no studies with specific deep cervical extensor strengthening.  Adding this component to a multi-disciplinary approach of balance and strength training, could reduce overall risk, especially with tasks involving cervical movements.

The modern rehabilitation of Cervicogenic Dizziness is now transforming into additional sensorimotor training aspects instead of just manual therapies.  The multisensory integration in neck pain and dizziness arises from multiple sources and deep cervical extensors can be highly involved in impaired on clinical examination. We include deep cervical extensor training into our Physio Blend, which helps to improve outcomes in this population.


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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