Should you recommend surgery for Cervicogenic Dizziness?

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

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

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

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

Here is a glimpse of the literature with accompanying conclusion:

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

 Ren L et al 2014

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

“Good results following more extensive cervical surgery”

Park J et al 2014

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

Liu XM et al 2017

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

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


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

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

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


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

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

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

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

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

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

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

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

The third thing I did—write this blog.

Big key points:

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

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

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

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

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

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

Authors

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

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Everyone loves a buffet – Cervicogenic Dizziness Style

Cervicogenic Dizziness, Cervical Vertigo

Happy 2018 everyone!  This year, I am completing my first decade of work as a Physical Therapist—wow, can’t believe it.  I believe I am now considered an oldie…the dinosaur…in our field!

I hope all of my colleagues and readers are continuing to enjoy the profession. Like you all, I continue to have the challenges, failures, and tribulations with clinical practice.  Hopefully these get fewer and fewer between but still very normal even with experience—its the beauty of physiotherapy…of healthcare.   I continue to aim high and hopefully the defeat gets buried away, hidden underneath the hours you spend beating on your craft.  Continue to pursue greatness to propel yourself and our field.  Always remember, have fun as we are very fortunate to change lives everyday.

Over the years, the pursuit of additional training and knowledge has led me down many paths.  As you all are aware if reading this blog over the past year, professionally, I have taken the challenge of being part of a continuing education company,; specifically, teaching the Differential diagnosis & the Manual and Therapeutic Exercise Management of Cervicogenic Dizziness.

The beauty of this condition is that it is a very specific diagnosis—one of which is still controversial, yet, responds very well to multiple treatment approaches throughout the literature.  Unlike treatment approaches in other fields of medicine, you would think that a specific diagnosis would lead to a specific treatment.  But, just as gray as PT can be, this just isn’t true.  Cervicogenic Dizziness can improve with a taste of ALL we have to offer.  Hell, we can just talk to them and give some general exercises and they improve…but can we do more?  Can we achieve better results?!

This is what the Physio Blend is all about.  It is my specific approach incorporating a taste of ALL we can offer that is achievable no matter your skill level and previous training; including signature soft tissue spots, upper cervical spine joint work, vestibular, pain-relieving and sensorimotor exercises—all packaged together smoothly to maximize results.

It is really our whole package of what we do as a profession.  Its the whole buffet.

If you want to treat concussion, treat whiplash, treat BPPV or even the elderly with balance disturbances, AND be evidence-based in 2018, this is where it’s at.  Feel more confident in your differential diagnosis and be more confident in attacking the upper neck as your resolution this year. You may push and prod on the upper neck and make change, but always know, the desserts are at the end of the buffet.  You may be missing other applicable manual therapies, other applicable exercises, and other applicable confidence to give the entire experience that your patients deserve.

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

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

 

 

Should you use Cervical Distraction to diagnose Cervicogenic Dizziness?

Cervicogenic Dizziness, Cervical Vertigo
Courtesy: https://medisavvy.com/wp-content/uploads/2017/03/Cervical-Distraction-Test.jpg

Cervical Distraction Test, or also known as Foraminal Distraction Test or Neck Distraction Test, is a common orthopedic test.  It has historically been utilized and studied to determine nerve root compression indicating a diagnosis of cervical radiculopathy, especially in the prevalent lower cervical spine.  The diagnostic utility is fair to poor (less than a coin flip) in regards to screening, but has promising value to be a specific test.  Additionally, the test is 1 of 5 variables that, if positive, indicate that a patient would benefit from cervical traction through a preliminary CPR back in 2009.  The latter makes common sense and for most of you reading, it has probably been preached to you in your graduate studies.  Nevertheless, a positive test is not an encouraging screen to help your clinical reasoning to rule out nerve root compression, but can aid later in your examination to rule it in.

Cervicogenic Dizziness (CGD) or also known as Cervical Vertigo, is caused by an aberrant or erroneous somatosensory afferent input from the cervical spine into the central nervous system centers causing vague disorientation and dysfunction in postural control.  The particular origin of altered somatosensory dysfunction could arise from multiple structures but typically stems from the upper cervical spine proprioceptive and muscle spindle sensitivity.

The question remains, should you use Cervical Distraction to diagnose Cervicogenic Dizziness?

Considering it is well understood that the dysfunction is in the upper cervical spine associated with Cervicogenic Dizziness, the reader can question why a diagnostic test, typically associated with the lower cervical spine, is utilized as diagnostic criteria?

The use of Cervical Distraction in the diagnostic criteria for the diagnosis of Cervicogenic Dizziness, to my knowledge, has been declared in two reports from the literature.

The first comes from Rob Landel, who can be considered one of the leaders in the education of CGD, describes a case report at the WCPT in 2015.  Clinical findings suggested there was no central or peripheral vestibular involvement, CNS or cardiovascular impairment, and that vestibular migraine was unlikely.  Based on previous experience with patients presenting similarly, a trial of cervical traction in sitting was attempted and proved successful, suggesting CGD. Accordingly supine manual traction was applied, with symptom resolution that lasted for 15–20 minutes. The patient was instructed in home traction using a towel tied to a doorknob, DNF and JPE exercises.

The second comes from a recent 2017 review entitled, “How to Diagnose Cervicogenic Dizziness” by Reiley et al.  This is a phenomenal article by the way and I highly recommend reading.  It follows along very nicely with my Optimal Sequence Algorithm (previous blog posts here, here, and here).   Quoting Richard Clendaniel’s book in 2014,  the authors state, “a reduction of dizziness symptoms in response to cervical traction implicates involvement of the cervical spine and is more consistent with CGD than with vestibular dysfunction. It is best to perform traction with the patient sitting in order to minimize the effect of gravity on the vestibular system”.

The question remains, should you use Cervical Distraction to diagnose Cervicogenic Dizziness?

Within several other disciplines (chiropractic, osteopathic, surgical), it is hypothesized that the dysfunction in the upper cervical spine stems mostly from pathology in the lower cervical spine.  The dysfunction is mostly described as a facet joint problem or cervical disc problem, especially degenerative in nature.  From a physiotherapist’s viewpoint, this can be conjectured from a postural issue, such as forward head posture, placing the upper cervical spine in extension in relation to a more flattened, mid-cervical spine.  In a nutshell, this can lead to overactivity of the superficial cervical musculature and increased tone in the upper cervical extensors.

So yes, a positive Cervical Distraction Test (abating concordant symptoms) could very well be diagnostic in the diagnosis of Cervicogenic Dizziness.  However, I would be highly suspicious of this test alone, as one test is no test, and used only after excluding other causes.  Outside of the above two citations, the use of this test as in inclusion criteria is absent in every other piece of literature, including the most rubust RCTs for Cervicogenic Dizziness to date.  Therefore, we have to question its validity in this specific population.  As a diagnosis with controversy between professions, you have to have a powerful and step-wise examination approach.

Even in a diagnostic test that is considered specific, we have to be aware of the non-specific effects of a practitioner’s hands on someone in a relieving manner as this could cause a great deal of false-positives. Asking a patient if their symptoms are better after you distract their neck (which is relieving to anyone!) can certainly make a non-mechanical cause of dizziness more comforting.

Therefore, using the Cervical Distraction Test for Cervicogenic Dizziness judiciously, alongside appropriate clinical reasoning and in the correct order in examination can assist in your final diagnosis.

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

Canadian C-spine Rule. And HOW does this relate to Cervicogenic Dizziness?

Cervicogenic Dizziness, Cervical Vertigo

The Canadian C-spine Rule is one of the most useful, reliable and valid differential decision making tools in our arsenal. As a very sensitive tool, it is a phenomenal screen for clinicians to rule out a cervical fracture. This is especially important prior to what rehabilitation clinicians do for a living—apply some type of local cervical treatment as it would obviously be an absolute contraindication to treatment.

Even if a PT is unable to fully cite the decision rule, most, if not all are aware of it and its purpose following a low or high trauma. How many of you would treat your MVA and/or concussion patient without having at least plain films performed by a physician? But there is one element that gets overlooked— and that is the ORDER of the various criteria that guide decision making.

As you can see from Figure 1 below, the clinician should NOT ask the patient to actively rotate the neck PRIOR to ruling out high risk factors and THENlow risk factors. There is a top-down approach, which makes the rule THE rule.

Harrison N. Vaughan – Canadian C-spine rule – Cervicogenic Dizziness

Makes sense right?…So then, shouldn’t we think of an optimal sequence, or order, prior to intervening to the cervical spine. This is especially important when you’re talking about a diagnosis of exclusion, one of controversy, one that may not be on a vestibular therapist or physician’s radar—and that is Cervicogenic Dizziness.

But while we talk about ruling out fracture, which is quite easily performed with plain film imaging (and additionally a CT Scan if you get into the emergency literature…); we have to clinically address other major contraindications to intervention—including central disorders, peripheral disorders, vertebral-basilar insufficiency (VBI) and even instability due to ligamentous tears.

These contraindications are MUCH more challenging, more gray but highly important as we are talking about dizziness here!—we don’t have the data points of highly sensitive or specific measures to rule out these conditions but at the same time, we have a very powerful tool to get these patients better, and better quickly. It is certainly a dilemma.

Cervicogenic Dizziness. Harrison Vaughan. All Rights Reserved.

Become more confident at addressing the upper cervical spine. Do your concussion, MVA and BPPV patients a favor. Learn my Optimal Sequence Algorithm for Cervicogenic Dizziness. It takes you through the clinical reasoning, the clinical tests and just as important, the ORDER, of addressing a patient concerned of having dizziness from cervical origin. This is the Canadian C-spine Rule on steroids. Then you can pound out results with the Physio Blend. ALL in a weekend—ALL taught by husband-wife combo who are specialists in manual therapy AND vestibular therapy—BOTH neuro and manual combined—ALL in ONE.

Cervical Vertigo, Cervicogenic Dizziness Courses, Vestibular, Cervical
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

Cervicogenic Dizziness – the data needs more data!

Cervicogenic Dizziness, Cervical Vertigo

One of my favorite excerpts from an editorial in quite awhile…

Clinicians should quit looking for
overly simplistic answers. Clinical
diagnosis, like producing a great wine,
is complex and requires an appreciation
of the data that can be gathered
within the nuances of patient interaction

Hegedus, Wright & Cook 2017

I do not think I am alone when we all learned clinical tests, or special tests, in PT school, it was one of the coolest things ever! It was gratifying to go from theory to “practice” and actually be able to diagnose something!  Unfortunately, as I continued to learn more, this bubbled busted—and busted with explosive power.

If only it was that easy.

The recent editorial, entitled “Orthopaedic special tests and diagnostic accuracy studies: house wine served in very cheap containers” in BJSM by Hegedus/Wright/Cook (free to access) brings to light the errors associated with clinical diagnostic tests with overall intention of clinicians to utilize clinical reasoning on refined data.

We have these special tests for cervical vertigo / cervicogenic dizziness–i.e. joint position error testing and cervical torsion tests, to aid in our hypothesis—but unfortunately, just like diagnostic tests to rule in hip/shoulder impingement and meniscal tears–these are limited.

So when you ask someone about the diagnosis of Cervicogenic Dizziness—back away if he/she quickly throws at you Joint Position Error Testing—even though this is promising, we are better than that.  We should be better than that. JPE testing will simply add more data to the already established data.  The already established data is a stronger foundation, a safer foundation, for your clinical examination.

I have spent the last few years of my clinical career examining every article published (in multiple languages!) coupled with clinical practice to provide the most optimal diagnostic process to put together my Optimal Sequence Algorithm.  In my personal opinion, I think this diagnosis is the most controversial (besides SIJ!), but ultimately takes the gold medal in clinical reasoning due to the often, and intimidating, nature of dizziness in non-benign conditions, including vascular and other central disorders.  No one should be comfortable jumping into the upper neck with someone experiencing dizziness without sound judgement and training.

As previously quoted, “clinicians should stop looking for overly simplistic answers”.  Let me help guide your thought process in this unnerving and overwhelming part of the human body.  These patients are walking in your door—let me help you get them better.

My next course is in Richmond, VA on November 4-5, 2017.   Sign up by October 1, 2017 for a $100 Discount!

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

 

 

Cervicogenic Dizziness is FINALLY here!

No automatic alt text available.

I’m super stoked to finally say that the day has come! After over 3 yrs of developing and 2 kiddos later, Danielle and I have our first course on Diagnosis and Management of Cervicogenic Dizziness this coming weekend!

I don’t think you’ll be let down as our manuscript (included with each course) has—
> 60,000 words
> 550 references
> 250 pages
> 65 tables/figures

—all in the ultimate package to diagnose (including ruling-out) competing disorders through the Optimal Sequence Algorithm and evidence-based treatment approach of manual therapies and sensorimotor training through the Physio Blend.

2 days (16 CEUs) of goodness combining the thoughts and actions of a “manual PT” and “vestibular PT” — myself and my wife, Danielle.

I hope you get to join us sometime to experience how you can maximize in helping your patients with BPPV, giddiness/unsteadiness, WAD and post-concussive syndrome.

Let me know if you’re interested and see if we can come to a city near you!

Harrison

Save $100 if register by TONIGHT, 7/28/17 (midnight) for Cervicogenic Dizziness Course!

Cervicogenic Dizziness, Cervical Vertigo

Last chance to sign up for my August 12-13, 2017 Cervicogenic Dizziness Course in Wake Forest, NC and SAVE $100!   Sale ends tonight, 7/28/17, at midnight.

Each participants receives a 250 page manuscript written by the instructors!  With over 600 references, you will not find any other evidence-based approach as detailed and concise as this one!

Cervicogenic Dizziness, Cervical Vertigo, Concussion, Whiplash


Maximize your outcomes with your concussion, whiplash and dizzy patients!

Do you think dizziness is coming from the neck but unsure how to diagnose it correctly?

Are you sure that you are ruling out central and vascular disorders to be confident in treating the neck?

Learn how to diagnose Cervicogenic Dizziness through the Optimal Sequence Algorithm and the most evidence-based approach to management with the Physio Blend—only through ICC Seminars.

Should you Manipulate a patient with Cervicogenic Dizziness?

Cervicogenic Dizziness, Cervical Vertigo

vertigo

It is now well known through documented basic science research and clinical trials that a subtype of dizzines can occur from dysfunction of the afferent input to the vestibular nuclei arising from the cervical spine, particularly C0-3.  However, the treatment approaches do vary widely in the literature with many accounts showing benefit from therapeutic exercises, education, vestibular rehabilitation, acupuncture, massage, mobilizations and manipulations.

Spinal manipulation continues to be a heavily debated topic due to its possible adverse events & specifically the risk of causing undue stress on the vertebral arteries in the V3 segment with a rotational manuever.  However, it continues to be an effective procedure for cervical spine dysfunctions and may be more effective than massage or mobilizations.

In fact, the effective delivery of manipulation over mobilization/massage could make sense to the practitioner based off of clinical results (personal experience) but also basic science from the findings of Bolton and Budgell 2006, which suggest,

that manipulation provides an immediate and short-term stimulus to the intervertebral tissues and that it is unlikely that deep short intervertebral muscles would be similarly activated when manual therapy is applied to superficial tissues

bolton

The application of spinal manipulation, especially to the upper cervical spine, is still contentious.  Even with this disputable intervention, there are multiple accounts of the use of spinal manipulation in the literature for the treatment of cervicogenic dizziness (to name a few – Cote 1991, Uhlemann 1993, Bracher 2000, Galm 1998).  It has been advocated that the therapy of choice is manipulation (Hulse 1975).

In fact, Heikkila et al 2000 found when comparing acupuncture, NSAIDs and cervical manipulation that,

spinal manipulation may impact most efficiently on the complex process of proprioception and dizziness of cervical origin

 

However, the leading expert in cervicogenic dizziness, Dr. Timothy Hain, disagrees with the use of spinal manipulation with this quote:

we generally think that chiropractic treatment is not a good idea for vertigo of any type, including cervical vertigo

Granted, Hain is speaking of chiropractic but we all know this relates directly to manipulation.

Additionally, Fraix M et al 2013, an osteopathic physician and his group that has studied the effects of osteopathic manipulative therapy in a pilot study in 2010, then again in 2013 and Papa in 2017, purposely did not manipulate the upper cervical spine due to “possibly a pronounced effect on the vestibular system”.  Further, many clinicians note that non-thrust techniques may better serve the suboccipital region.

Thus, the literature is still pending on the use of spinal manipulation for the management of cervicogenic dizziness as it does not always seem logical (Duquesnoy & Catanzariti 2008).   Beyond the scope of this piece but very relevant is the type of manipulation in a patient with dizziness—such as, would it be more appropriate to perform a non-momentum induced thrust vs momentum induced thrust in someone with dizziness induced by head on neck positions?

The author of this manuscript considers spinal manipulation, but knows the effectiveness of other articular and non-articular methods of manual therapy.  It is not to say spinal manipulation isn’t safe, as it can be very safe if provided in the right context.  The application of one over the other entails many facets of patient management, including psychomotor skills, prior experience (patient and clinician) and a thorough assessment.

What are your thoughts?  What kind of experience do you have with this topic?

Discounts for my Seminal Course! (expires July 28th at midnight!)

if signing up with colleagues (3 or more)

Use code: Group for $50 off each

or if signing up as student or new grad (within 2017)

Use code: STUDENTCGD for 70% off!

Sign up for more emails on this topic by clicking here

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 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

 

Cervicogenic Dizziness Course – Sale ends July 5!

Cervicogenic Dizziness, Cervical Vertigo

Cervicogenic Dizziness, Cervical Vertigo,

Happy July 4th to all my readers!

If you’re interested in taking my seminal course on Cervicogenic Dizziness, we have a Sale going on right now to cut down on your cost!  Next 2-day course is in Raleigh, NC on August 12-13, 2017.

Use code: Vista25 for $25 off 

or if signing up with colleagues (3 or more)

Use code: Group for $50 off each

or if signing up as student or new grad (within 2017)

Use code: STUDENTCGD for 70% off!

Course includes learning the Optimal Sequence Algorithm and Physio Blend, a 220 page manuscript (yes, 220 pages!), for differential diagnosis and ability to maximize your results with patients who have BPPV, post Whiplash, post Concussion, elderly patients with balance disturbances, simply neck pain and of course, single entity of Cervicogenic Dizziness Diagnosis.

Contact me at harrisonvaughanpt@gmail.com for more information.