Can Chiropractic care Cervicogenic Dizziness?

Cervicogenic Dizziness, Cervical Vertigo

Cervicogenic Dizziness, Cervical Vertigo,

Can Chiropractic help Cervicogenic Dizziness?

A 2019 online survey by Vindengi et al entitled, “Chiropractic treatment of older adults with neck pain with or without headache or dizziness: analysis of 288 Australian chiropractors’ self-reported views” was recently published. 

One reason we decided to examine this paper was to:

  1. not only to confirm that manual professionals (such as chiropractors) do successfully treat neck pain and dizziness, but also
  2. to determine how often manual professionals (such as chiropractors) see & treat patients with neck pain and dizziness. 

This is important to the physical therapy professionals, especially ones who treat dizziness (i.e. vestibular therapists) for one major reason:

  1. If these patients are seeking out (usually on their own and not referred) to chiropractors for treatment of neck pain and dizziness, why aren’t they seeking out the practitioners who treat dizziness/vertigo/balance dysfunction in the elderly mostly or could go as far as sole clientele — which are our geriatric and vestibular physical therapists!

Cervicogenic Dizziness, Cervical Vertigo, Neck Dizziness

So to answer our first two questions above, here are direct conclusions from the paper:

Reason #1: not only to confirm that manual professionals (such as chiropractors) do successfully treat neck pain and dizziness, but also

  • Most chiropractors reported moderately positive responses (on a scale from no response to excellent response) to chiropractic treatments for dizziness in older adult patients with neck pain.

Reason #2: to determine how often manual professionals (such as chiropractors) see & treat patients with neck pain and dizziness. 

  • Respondents reported that over 44% of their older adult patients with neck pain were at risk of falls, and over one-quarter of them suffered from cervicogenic dizziness.

There you go.  Chiropractors do see of course elderly patients with neck pain and dizziness and get positive results in their treatments.  Also, interesting that they mention ~25% of them actually had Cervicogenic Dizziness.

I would imagine this is very similar to a PT outpatient office but two questions to mind:

  1. How many of our outpatient, orthopedic physical therapists are confident to treat dizziness as well?
  2. How many of our vestibular/neuro/geriatric physical therapy clinics are confident to treat neck pain as well?

I think these are very reasonable questions and unfortunately, I do not know the answer.

One of our major goals is to merge our profession to do just as this paper proved—a healthcare practitioner (in this case=chiropractors) can treat patients together with neck pain and dizziness.

We do think formal training in both can help and considering neither the big manual therapy training or big vestibular training focus on Cervicogenic Dizziness, we helped fill this gap with our course.


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

 

This is why you need to read studies and not just look at abstract

Cervicogenic Dizziness, Cervical Vertigo

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

The following is the conclusion of a 2019 prospective, multi-center, randomized controlled clinical trial examining the difference between cervical mobilizations and traditional massage in 360 adult patients with the diagnosis of cervical vertigo.

“No differences in outcomes were detected between the SCM {Shi-Style Cervical Mobilizations) and TM {traditional massage} groups in terms of treatment of cervicogenic dizziness. Efficacy trials are required to determine whether the improvement observed for each treatment was causally related to the interventions.”

From a birds-eye viewpoint, you can take this conclusion that massage therapy is just as good as cervical mobilizations for the treatment of cervicogenic dizziness.  Some may even take this piece of information further to state the massage therapists could be the ones treating cervicogenic dizziness.

Now, I don’t have a problem with massage therapists treating conditions! Heck, we have a very good colleague who we make referrals to and vice-versa in everyday clinical practice.  But, I do want to make a point with this blog that a clinician, or even patient, should be aware of differences in descriptions in various pieces of literature, especially if coming from a randomized controlled clinical trial.

From a physical therapist perspective, the use of massage and cervical mobilizations are typically separate procedures.  Hence, the reason we separate them in clinical trials to ascertain a difference or even a superiority, in techniques.  I want to place descriptions of Yao et al 2019 below so the reader can read for themselves that interventions are described very differently throughout the musculoskeletal field.

You can see from the descriptions that there is not only some overlap of “soft tissue areas” and “mobilizations”, but even so multiple sites of the body and locations in the extremities were used to treat these patients with cervical vertigo.  We agree that the treatment of cervical vertigo should not be so localized to one or two segments (which has been demonstrated to be effective in long term study), but blends mobilizations, soft tissue points and even sensorimotor training.

It is absolutely impossible to read the thousands, to millions, of research articles in the medical field each year.  We don’t expect that on any healthcare provider!

But, if you’re interested in the diagnosis and management of Cervicogenic Dizziness, we have done that work for you!  We constantly blog on new updates and have over 600 references in our book that inscribes the ink on an art form of manual therapy and sensorimotor training.  If you have taken one of our courses, thank you! If not, check out our upcoming course page or contact us to host a class!


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

Your patients with neck pain AND dizziness have higher disability

Cervicogenic Dizziness, Cervical Vertigo

Cervicogenic Dizziness, Cervical Vertigo,

When addressing disability and functional limitations for someone you’re suspecting to have Cervicogenic Dizziness, it is normal practice to use a combination of Neck Disability Index (NDI), Dizziness Handicap Inventory (DHI) to examine functional limitations for general neck pain and dizziness.  You will find this to be a frequent combo in the medical and rehabilitation literature for diagnosis of Cervicogenic Dizziness, but also for benign paroxysmal positional vertigo (BPPV).

Cervicogenic Dizziness in a diagnosis of itself is most often contributed to less disability and functional limitations compared to other vestibular and central dizziness/vertigo diagnoses.  In fact, cervicogenic deficits have been shown to be subtler and less severe than deficits associated with vestibular and central nervous system (CNS) conditions (Field et al 2008, Treleaven et al 2005, Kristjansson et al 2009).

However, two studies I want to bring to your attention that could deflate this traditional thought:

  1. L’Heureux-Lebeau et al 2014 found that the intensity and handicap of the Dizziness Handicap Inventory was similar between Cervicogenic Dizziness and BPPV groups.
  2. Raul Ferrer-Pena et al 2019 Patients with non-specific chronic neck pain in conjunction with dizziness present higher health-related quality of life impairment and higher disability and kinesiophobia compared to patients with isolated non-specific chronic neck pain.

Now granted, the title of this piece only compromises these two studies compared to general thought-process as described above, but I like to ask, what do you see?

Wouldn’t you think a combination of not only having chronic neck pain, but a dizziness symptom, such as lightheadiness or unsteadiness be even more detrimental to your quality of life?

Cervicogenic Dizziness, Cervical Vertigo, Neck Dizziness

A multimodal approach of manual therapy, therapeutic exercise, vestibular and sensorimotor training within a biopsychosocial framework works best for Cervicogenic Dizziness.

Cervicogenic Dizziness, Cervical Vertigo, Neck Dizziness

The combined effect of these two pathologies, both neck pain and dizziness, has the greatest impact it has on health-related quality of life.  In principle, isn’t this what we do for a living?  Improve quality of life?  Allowing our patients to have the best health he/she could imagine?

Why not be efficient in treating both conditions at once?


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 have a blade needle to your neck or this for Cervicogenic Dizziness

Cervicogenic Dizziness, Cervical Vertigo
Needle Knife Acupuncture: Picture from China Quad Diaries

Needle-knife therapy can be used during an acupuncture treatment and claimed to be useful on soft tissue injuries and could help to relieve neurovascular compression by relaxing soft tissues in order to relieve tension pain.

In fact, an article by Yang et al 2019 investigated the therapeutic effect of blade needle therapy for cervicogenic dizziness and changes of blood flow of vertebral artery in patients with cervicogenic dizziness.

The article was entitled, “Blade needle treatment improves cervicogenic dizziness by increasing blood flow of vertebral basilar artery” in the Zhen Ci Yan Jui Journal.

The conclusion of the article is the following:

Blade needle treatment has a good clinical effect in the treatment of CD patients, which is probably associated with its function in increasing blood perfusion of the brain tissue, and thus being worthy of clinical application.

As physical therapists who treat this condition and NOT acupuncturists , or even trained in blade needle treatment, I wonder if this type of therapy is absolutely necessary to obtain similar or even superior results for the resolution of cervicogenic dizziness.

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

Nevertheless, I would say, for what it is worth, a quick search on this topic yielded better results in blade needle therapy vs acupuncture-cupping in a 2014 study by Cao et al. 

Even though the highest level of evidence thus far for Cervicogenic Dizziness is a meta-analysis (Hou et al 2017) of acupuncture (not necessarily blade needle treatment), we also have several systematic reviews showing effectiveness of manual therapies of non-skin penetrating format, such as Yaseen et al 2018. 

Even though blood flow is one of 3 major hypothesis for the origin of Cervicogenic Dizziness, we now know that the major theory for diagnosis and potential effective treatment is to address the proprioceptive dysfunction, rather than vascular and/or neurovascular aspect that could potentially cause symptoms of lightheadiness, unsteadiness and dizziness.

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

This type of treatment approach could definitely help with symptoms, but with latest knowledge on head on neck orientation, benefit of cervical strengthening and endurance, and even sensorimotor integration with patients who have dizziness and altered orientation disorders, it could be more worthy to seek out a combination of manual therapy, exercise, vestibular and sensorimotor approaches to address the diagnosis of Cervicogenic Dizziness.

Just our two cents.


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

 

 

Does Anxiety cause Cervicogenic Dizziness?

Cervicogenic Dizziness, Cervical Vertigo

Cervicogenic Dizziness, Cervical Vertigo,

Does Anxiety cause Cervicogenic Dizziness?

Dizziness and psychological (i.e. anxiety and/or depression) issues usually coincide.

Pain and psychological (i.e. generalized anxiety) issues usually coincide.

These are called comorbidities and we should be aware of them as healthcare professionals.

Even though these symptoms are different, they occur parallel in a multi-system condition such as Cervicogenic Dizziness. It is well known that dizziness, psychological disorder and pain are multifaceted, interacting and interfering entities rather than as separate insusceptible issues. Therefore, for someone with Cervicogenic Dizziness, you are already 2 strikes towards having a psychological disorder.

When dizziness persists without findings of significant vestibular or central deficits, a clinician should respect that the remaining symptoms are often associated with a psychological disorder. Consistent with Cervicogenic Dizziness being defined as a ‘diagnosis of exclusion’, the psychological aspect should always be considered with our patients who have pain and dizziness.

Simply put, we always do a checks & balance approach — did the psychological distress lead to the symptoms or persistent, ongoing, chronic symptoms lead to the psychological distress?

Manual Therapy to the neck for Cervicogenic Dizziness

Should physical therapists address anxiety and depression?

Even though the physical therapy profession is learning (and leaning) more towards the understanding of the “psychosocial” aspect of illness, I find I screen and address this component, but focus on the “bio” aspect of bio-psycho-social realm of illness. Our strongest attribute to the Cervicogenic Dizziness population is to determine if the consequence of dizziness is from a pain location, particularly of the upper cervical spine.

If you suspect a high influence of psychological triggers, I say this is outside our scope of practice and recommend referring out to appropriate professionals. Even though we have had some training in this realm in our entry level education, we should let the ones who specialize in this figure out what psychological distresses enhance and sensitize the central mechanisms and hinder healing.

What you can do to screen for anxiety and depression.

Therefore, you as a clinician can provide screens to help you make this decision. Here are three recommendations:

  1. Find a psychological professional in your community to meet with for coffee/lunch to discuss this topic.

    • You can figure out what his/her approaches are to help, such as psychological therapy and/or medications. This doesn’t mean you “lose” the patient to this professional, but more of a mutual relationship to provide optimal interventions in clinical management.

    • I always try to find someone that you can simply text/email with quick questions and form a friendship bond.

  2. Use the emotional subscale of the Dizziness Handicap Inventory (DHI).

    • There are functional, physical and emotional subscales of the DHI. You are most likely already using this scale in your rehabilitation setting prior to seeing the person!

    • For true Cervicogenic triggers for the Dizziness symptoms, we find less positive findings on the emotional questions and more positive findings on the physical questions.

    • This statement, general as it may be, coincides with Dr. Susan Reid’s 3 dimensional screen of the DHI in her research. A patient is twice as likely to have Cervicogenic Dizziness if the following is true on the DHI:

      • “YES” on P1 question: Does looking up increase your problem?

      • “YES” on P11 question: Do quick movements of your head increase your problem?

      • “NO” on E9 question: Because of your problem, are you afraid to leave your home without having someone accompany you?

  3. Use other screening questionnaires that a psychological professional is familiar with.

    1. The GAD-7 (Generalized Anxiety Disorder) is a seven-question screening tool that identifies whether a complete assessment for anxiety is indicated. You can find it here.

    2. The Duke Anxiety-Depression Scale (DUKE-AD) is a brief, easily scored questionnaire that serves as a valid screener in primary setting. Even though this scale is more protected and not widely available online, you can read more about it here.


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  

Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes addressing the articular and non-articular dysfunctions of the neck; as well as graded exercise, vestibular and sensorimotor approaches. 

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

AUTHORS

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Big Fist Bump for Cervicogenic Dizziness Manual Therapy Evidence

Cervicogenic Dizziness, Cervical Vertigo

It is well known now through high level evidence that seeing a physical therapist is the correct approach to managing Cervicogenic Dizziness.  In fact, it can be said with confidence that Manual Therapy, such as joint mobilization/manipulation and soft tissue mobilization/manipulation to the cervical spine, is the best way to treat symptoms associated Cervicogenic Dizziness.

Cervicogenic Dizziness, Cervical Vertigo, Neck Dizziness
Manual Therapy approaches for Cervicogenic Dizziness

Yaseen et al 2018 (a systematic review) reiterated the results from Reid et al 2005 (a previous systematic review) and even bumped up the “level” of evidence to Level 2.  Having consistent results over a decade and even “higher evidence” through greater methodological studies is very solid research approach in the musculoskeletal field.

One of the reasons the level of evidence was bumped up from the systematic reviews in 2005 to 2018 was due to Susan Reid’s work on use of passive joint mobilization (Maitland) and SNAGs (Mulligan) for the management of Cervicogenic Dizziness.  Her team has published quality, high-methodological studies with even long-term results on the results of Cervicogenic Dizziness management.

Basically this translates to a very solid fist bump researchers and clinicians!  As a matter of fact, I can’t seem to name any other diagnosis that responds as confidently to manual therapy in the field of physical therapy.

What do you think of the consistent improvement in research for manual therapy in this field?  It seems to be improving while other diagnosis are expressing less manual therapy and more exercise.  We would love to hear your thoughts!


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 

Impaired Sensorimotor Outcome Measures for Clinicians

Cervicogenic Dizziness, Cervical Vertigo

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

Cervicogenic Dizziness, Cervical Vertigo, Joint Position Error Testing

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

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

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

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

1. Dizziness Handicap Inventory (DHI)

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

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

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

You can download a copy of the DHI here.

2. Visual Complaint Index

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

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

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

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

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

You can download a copy of the Visual Complaint Index here

3. Space and Motion Discomfort

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

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

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

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

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

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

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


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

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

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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

 

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

Cervicogenic Dizziness, Cervical Vertigo

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

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

What causes BPPV?

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

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

What factors lead up to having this diagnosis?

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

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

  1. Aging

  2. Migraine

  3. Meniere’s Disease

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

  5. Infection

  6. Vestibular Neuronitis

  7. Idiopathic sudden sensorineural hearing loss

  8. Sleeping habits

  9. Osteoporosis and vitamin D insufficiency

  10. Hyperglycemia and diabetes mellitus

  11. Chronic head and neck pain

  12. Vestibule or semicircular canal pathology

  13. Pigmentation disorders

  14. Estrogen deficiency

  15. Neurological disorders

  16. Auto- immune, inflammatory, or rheumatologic disorders

  17. Familial or genetic predisposition

  18. Allergy

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

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

Vestibular Therapy to Treat Cervicogenic Dizziness

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

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

How does BPPV relate to Cervicogenic Dizziness?

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

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

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

#11 Chronic head and neck pain

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


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  

Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes addressing the articular and non-articular dysfunctions of the neck; as well as graded exercise, vestibular and sensorimotor approaches. 

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

AUTHORS

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Can True Vertigo be a Symptom of Cervicogenic Dizziness?

Cervicogenic Dizziness, Cervical Vertigo

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

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

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

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

Cervicogenic Dizziness, Cervical Vertigo, Neck Dizziness

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

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

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

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

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

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

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

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


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

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

Sign up for more emails on this topic by clicking here

Authors

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

2 Mistakes You Could Make with Cervicogenic Dizziness Diagnosis

Cervicogenic Dizziness, Cervical Vertigo

Cervicogenic Dizziness, Cervical Vertigo,

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

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

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

Cervicogenic Dizziness

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

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

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


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

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

Sign up for more emails on this topic by clicking here

Authors

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

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