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

Cervicogenic Dizziness, Cervical Vertigo

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

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

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

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

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

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

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

In relevance to Cervicogenic Dizziness:

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

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

Here is an interesting quote from the article,

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

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

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

Quote from the author’s in conclusion:

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

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

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

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

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


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

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

Authors

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

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

Cervicogenic Dizziness, Cervical Vertigo

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

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

The question is, why?

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

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

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

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

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

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

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

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

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

Image result for acupuncture dizziness neck

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

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

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

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

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

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

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


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

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

Authors

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Why is recent infection a precaution to orthopaedic manual therapy?

Cervicogenic Dizziness, Cervical Vertigo

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

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

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

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

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

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

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

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

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

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

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


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

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

Authors

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

Do THIS before performing Dix-Hallpike Manuever

Cervicogenic Dizziness, Cervical Vertigo

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

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

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

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

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

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

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

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

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


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

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

Authors

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Stroke following cupping therapy AND a massage? WHAT?!

Cervicogenic Dizziness, Cervical Vertigo

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

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

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

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

Choi et al 2016

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

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

Dutta et al 2018

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

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

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

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

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


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

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

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Authors

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

How common is Cervicogenic Dizziness?

Cervicogenic Dizziness, Cervical Vertigo

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

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

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

Elderly / Geriatrics

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

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

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

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

 

Whiplash

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

Non-Traumatic Cervicogenic Dizziness

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

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

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

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

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


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 1st day includes the “Optimal Sequence Algorithm”, a multi-faceted physiotherapist approach to the assessment of Cervicogenic Dizziness, which includes the appropriate ruling-out process and cervical examination of the articular and non-articular systems. Also pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

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

Authors

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

Concussion: Purely a brain injury or are there more pragmatic treatments?

Cervicogenic Dizziness, Cervical Vertigo

Concussion has been a hot topic in the last few years and continues to grow in awareness, diagnostic and treatment options in the field of medicine.  Rehabilitation professionals, such as physical therapists, play a vital role in recovery from this injury and can be argued to be the best healthcare provider to aid in a progressive, graded exposure to return to sport/play.  Treating patients recovering from this injury can be challenging but our field offers us the training and ability to address the multiple dimensions of symptoms; including the oculomotor, vestibular, cervical and central impairments.

Even though concussion can be considered physiologically a “brain injury”, there is a plethora of data correlating the mechanism of injury and impulsive forces to whiplash mechanism, such as seen in a car wreck (Elkin et al 2016, Alexander 2003, Hynes & Dickey 2006, Morin 2016).  So not only could impulsive forces in concussion involve the head, but the neck as well (Marshall 2015, Kennedy 2017).  This is not a new subject per say, but with the continued expression of “brain injury” and “central condition”; I want to express to my colleagues that symptoms of headache and dizziness could be generators of nocioception and/or alterered proprioception.  There have been some authors to go as far as suggesting concussion should be appropriately called the monikor craniocervical shaky syndrome (CCSS).

Instead of simply allowing the brain injury diagnosis sticker dampen the prognosis to allow healing to occur, it is recommended to consider the cervical spine a potential reason/cause for post-concussion persistent symptoms.  Considering dizziness after sport-related concussion is common and reported to be in 43-81% of cases (Alslaheen et al 2010, Duhaime et al 2012, Lau et al 2011), it is highly recommended to get the formal assessment, evidence and treatment for these patients.

Let’s move on together to aid in finding potential, pragmatic and VERY treatable region of the body.  It can be challenging to find which system is of particular importance in the driver of post-concussive symptoms, but if you think it is the cervical spine, we have the answers for you.


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 1st day includes the “Optimal Sequence Algorithm”, a multi-faceted physiotherapist diagnostic approach of Cervicogenic Dizziness, which includes ruling out central and peripheral disorders to rule in the cervical spine as driver of proprioceptive dysfunction.

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

Authors

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

 

 

Is Osteopathic Treatment effective on Cervicogenic Dizziness?

Cervicogenic Dizziness, Cervical Vertigo

While answering the question, “Is Osteopathic Treatment effective on Cervicogenic Dizziness”, I must preface to say I am not an osteopathic physician and do not practice in that theoretical construct.  However, for those readers who understand the mechanisms of manual therapy and history behind the field of Physical Therapy and Osteopathic medicine; I am sure you can appreciate the correlation of Osteopathic medicine and subset of Manual Therapy within the larger scope of practice in Physical Therapy.  Here is a synopsis if you haven’t delved into the history.  Understanding this correlation will allow the clinician to delve deeper into the literature of other professions in order to have a broader consideration of the effects of manual therapies on individuals suffering from Cervicogenic Dizziness and ultimately give your patients the most comprehensive treatment.

While inquiring PubMed for literature support, unfortunately the terminology of Cervicogenic Dizziness comes up empty.  Why?  Well, read a previous post for that.  Nonetheless, Cervical Vertigo brings me information from Hulse et al in 1975.  As expected, the thought process realms from disturbances of the upper cervical spine and the authors recommend manipulation as treatment of choice.

As the years go by, it is difficult to find literary works specifically for the benefit of Osteopathic treatment for Cervicogenic Dizziness.  However, we do have a some information provided by:

  • A case report by Kennedy in 2002
  • A case report by Shaffer in 2005
  • A case report by Fraix in 2009.
  • A case series by Berkowitz in 2009.
  • A case report by McCallister et al 2016 – of note, this was on a patient with severe TBI

Since these are in the lower levels of evidence, the main chunk of justification doesn’t start until when we delve into Fraix’s work in 2010.  A pilot study, here is Fraix’s conclusion

This study showed that OMT is generally well tolerated in patients with vertigo. It also demonstrated that it is feasible to recruit a population of patients with vertigo who can complete a course of OMT and collect data by using the DHI. A randomized control trial that examines the efficacy of OMT in patients with vertigo is warranted, given that OMT may be a reasonable treatment for vertigo and the functional impairment associated with it.

Of course this study has limitations, but I do like how it uses the Dizziness Handicap Inventory (DHI) as a functional outcome measure to show effectiveness of the intervention with a validated and reliable outcome measure.  See results in Figure 1 from the article below:

Fraix 2010

As far as I know, a follow-up RCT designed to compare Osteopathic Treatment to Vestibular Rehabilitation never made it to publication.  However, we do have some other evidence of the effects of osteopathic treatment in the last few years.

In 2013, Fraix and colleagues in a prospective clinical cohort study evaluated the effect of osteopathic manipulative treatment (OMT) for spinal somatic dysfunction in patients with dizziness lasting longer than 3 months.  Here is their conclusion:

Osteopathic manipulative treatment for spinal somatic dysfunction improved balance in patients with dizziness lasting at least 3 months.

Fraix 2013

In 2017, Papa and colleagues in a randomized control trial examined a group of 31 individuals with BPPV and again used DHI as outcome measure.  Here is their conclusion:

These findings suggest that OMT could be a useful approach to reduce imbalance symptoms and to improve the quality of life in patients suffering from dizziness

Papa 2017

In conclusion, the evidence is slowly, but starting to mount to give more credence to Osteopathic Treatment for Cervicogenic Dizziness.  I do not hesitantly justify this as simply another means of evidence denoting the benefit of manual therapy, which can be provided by trained physical therapists, for the treatment of Cervicogenic Dizziness / Cervical Vertigo.

The justification for our services and approaches are continuing to mount, for the sake of the patient, our referral sources, for us personally and for the 3rd party payers.  Anyone who has taken my courses knows evidence is a top priority and you will get the information you need to not only learn how to diagnose and treat Cervicogenic Dizziness, but the paper trail that puts more substance into our practice.


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

 

Would you harm a patient with manual therapy already diagnosed with concussion?

Cervicogenic Dizziness, Cervical Vertigo

The title of this blog is a loaded question, but generally speaking it entails the risk : benefit ratio and adverse events of performing manual therapy on a patient who has suffered a concussion.  In particular, we are speaking of someone who is suffering from post-concussive symptoms after mild traumatic brain injury (mTBI).  In this post, we will use mTBI synonymously with post-concussion symptoms. This patient is already in your office, you have determined some type of musculoskeletal generator for symptoms, most likely neck pain, dizziness and/or headache; so you proceed with what you have in your tool box.

Cervical spine involvement in mTBI is gaining more traction over the years. There have been countless case reports and case studies on the benefit of manual therapy for mTBI (to name a few–Gurnseley 2016, Burns 2015, Weltzer 2017).  In fact, Brolinson recommends using manual therapies alongside neuromotor/sensorimotor training for more effective  mTBI recovery than rest and exercises.  Also, we can’t forget the all important Schneider study from 2014 that found a significant number of athletes returned to sport in manual / vestibular group compared to control group.

Most recently, Quatman-Yates in 2016 found the following conclusion:

The results of this systematic review indicate that several physical rehabilitation options with minimal risk for negative outcomes are available for treating patients experiencing persistent post-mTBI symptoms. These options include: vestibular, manual, and progressive exercise interventions.

In general, the literature does guide us that manual therapies can be a safe and effective intervention to the cervical spine for mTBI.  In fact, if you break down adverse events in Cervicogenic Dizziness / Cervical Vertigo, you will not find the literature shying away from manual therapy either.  Even though no study has been conducted directly examining adverse events, it can be noted that the largest randomized control trial and long term outcomes to date by Reid and colleagues specifically state no adverse events in the group of eighty-six participants receiving manual therapy.

However, there is one study I want to bring to light.  It is from Dr. Greenman and his colleague, Dr. McPartland back in 1995 entitled, “Cranial findings and iatrogenesis from craniosacral manipulation in patients with traumatic brain injury“.  For those who do not know, Greenman was well known at Michigan State in Osteopathic Medicine and well cited in books and journals.  Even though the practice and treatment of craniosacral manipulation is beyond this blog and post, it is worth noting the findings of this brief review below:

Out of 55 cases, the authors describe 3 cases of adverse events of craniosacral therapy in patients with mTBI, including 2 requiring hospitalization.  They noted a 5% incidence rate and quoted the following, “craniosacral manipulation in a traumatic brain-injured patient can be useful and effective, but is not without risk”.

This number may not mean much to you—but we all hope as clinicians it is 0%—but it all depending on how you define iatrogenesis.  Nevertheless, I suggest you compare this number to Carnes’ 2010 study noting incidence estimate of proportions for minor or moderate transient adverse events after manual therapy was approximately 41% (CI 95% 17-68%) in the cohort studies and 22% (CI 95% 11.1-36.2%) in the RCTs; for major adverse events approximately 0.13%.

However, Sabel and Patini in 2018 in a pilot study examined safety of Osteopathic Manipulative Medicine in PostConcussion Symptom Management and elicited the following conclusion:

Osteopathic cranial manipulative medicine was considered a safe adjunctive treatment option to improve concussion-related symptoms and recovery.

In conclusion, I say there are minor adverse events to any intervention but we definitely want to have a treatment approach that minimizes risk while add benefit.  The type of technique, approach and handling skills can all be combined to making this formula turn out best for you and the patient.  In our Cervicogenic Dizziness Course, we teach a variety of techniques that add on what you already know and propel it towards maximal comfort and relief.  Come check us out near you.


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

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

Authors

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

How common is Cervicogenic Dizziness in Concussion?

Cervicogenic Dizziness, Cervical Vertigo

 

Concussion

Over 80% of concussions have been observed to recover within 7-10 days, but ~20% of sports-related concussions can take longer than this period of time to resolve.  Predictors and factors associated with a protracted recovery and reasons for post-concussive symptoms can be of many reasons but for the purpose of this post, we will delve into the cervical spine.

You can’t disagree that assessment of the cervical spine in post-concussion management and treatment is important.  However, the prevalence of cervical spine pathology in concussed patients is unknown.  Many authors express interest and promote the manual assessment of the cervical structures.  I recommend delving into the research by these authors: Leddy et al 2015, Gergen 2015, Scorza et al 2012Ellis et al 2015Craton et al 2017Cheever K et al 2016, Matsuszak et al 2016, Morin et al 2016Marshall et al 2015, Elkin et al 2016Putukian 2017, Lundblad 2017  , Schneider et al 2018 and Kosoy/Feinstein 2018.

Even though concussion research and awareness has spiked in the last few years, you can also go back to 1956 to read an article by Seletz in Calif Med Journal entitled, “Craniocerebral Injuries” (a free paper).  So, yes, this concept is not new.

However, if you’re looking for a newer model to adopt, I recommend reading Mark Lundblad’s work in 2017 paper in Int J Sport Phys Ther entitled, “A Conceptual Model for Physical Therapists Treating Athletes with Protracted Recovery Following a Concussion”.  He does mention that the first component to address (prior to neuromuscular control and strengthening) is cervical mobility and C1-2 should be of particular importance.

In regards to Cervicogenic Dizziness following Concussion, we don’t know the prevalence rates of Dizziness itself from the Cervical Spine but we do know most common symptoms are headaches, dizziness, fatigue and other range of cognitive deficits.  More research and scientific inquiry is on headaches vs dizziness from the cervical spine, but we can all agree even though we are looking at a proprioceptive vs nocioceptive alteration in input, that some of the actual structures at fault can be similar.

There will be tons more coming out in the concussion literature over the next few years to aid in prevalence rates themselves, but here are studies we present to our classes:

Just recently, Ellis et al 2018, in a retrospective cohort study, actually looked at Cervical Spine Dysfunction in Pediatric Sports Related Concussion.  Out of the 246 patients included in the study, 80 of them (32.5%) met the criteria for cervical spine dysfunction.  The authors conclude that cervical spine dysfunction can be a risk factor for delayed clinical recovery.

Kennedy et al 2017, in a retrospective chart review study, found that 32 of 45 (69.5%) of patients with persistent post-concussion symptoms, were found to have cervicogenic component.  The authors highlight the value of physiotherapy assessment and treatment of the cervical spine following a concussive injury.

Reneker et al 2018, in a cross-sectional study of athletes after a concussion, found 82.9% had cervical involvement and 26.8% presented with Cervicogenic Dizziness.

A classic, Schneider et al 2014, in a randomized controlled trial to treat concussion in adolescents, found 100% of patients in both treatment AND control group had cervical spine findings.  Moreover, 93.33% in treatment group had neck pain while 87.5% in control group had neck pain. Additionally, 86.33% had dizziness in treatment group and 82.75% had dizziness in control group.

Marshall et al 2015, albeit a review paper BUT also a case series, discusses the role of many theories causing post-concussive syndrome.   Pertinent to this post, the authors give credence to “a very treatable” cause of it—the cervical spine.  All of the cases demonstrate several different types of manual therapies to the cervical spine to aid in improving symptoms.

Growbaski et al 2017, in a retrospective cohort study, expressed that over 75% of the patients experienced symptoms consistent with peripheral vestibular disorder or cervicothoracic dysfunction, either in isolation or in various combinations, in their multimodal, impairment-based PT approach to treating post-concussion syndrome.

Browne GJ 2006 found that in the retrospective descriptive case series study of 125 children who injured their cervical spine while playing rugby football, 98% of them had neck pain (of course if injured neck), but out of these 125 children, 23% had a concussion.

Jensen et al 1990 found that 18 out of 19 (94.7%) patients with persistent post-concussive syndrome had upper cervical spine restrictions when compared to an uninjured control group. Their work concludes that it supports the hypothesis of a cervical mechanism causing post-traumatic headache and suggests that post-traumatic dizziness, visual disturbances and ear symptoms could be part of a cervical syndrome.

Treleaven et al 1994 demonstrated in 12 patients with post-concussive had upper cervical spine dysfunction compared to a normal control group.  This study examined headaches.

Going back even further, Mager et al 1989, noted a block of the upper cervical spine and of the cervicothoracic area was proved in 83.53% of patients who were hospitalized upon a head injury.

How common is Cervicogenic Dizziness after Concussion?

The values above are just several examples of prevalence rates of cervical component in head injury from concussion. Unfortunately, I don’t have specific values for you as most studies lump Cervical Dysfunction as criteria to treat musculoskeletal symptoms or Dizziness symptoms in peripheral disorders but don’t differentiate between the two.

However, we can at least appreciate that 1/4 of patients (25%) with concussion have Cervicogenic Dizziness following results of Jennifer Reneker’s work in 2015 BUT could be as high as 86% in Schneider’s work in 2014.  What do you see in the clinic?  Do you think the percentage is larger than what is presented in the research?

I hope this provides you some phenomenal information to take back to the clinic!  Overall, we can definitely rule out the cervical spine via a few tests and if you can’t rule it out, we do have some specific tests to aid in ruling in the condition.

Also—keep in mind, this data doesn’t include the plethora of information from the whiplash-associated disorder diagnoses either!  You will see a future post on this data so sign up for email alerts! If you’re seeing head injury patients, post-concussion syndrome, and even whiplash and do not address the cervical spine, I hope this post gives you credence to examine it further.


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