Suspecting a patient has VBI? You could recommend this.

Cervicogenic Dizziness, Cervical Vertigo

Cervicogenic Dizziness, Cervical Vertigo,

The probability of a patient arriving to your outpatient, physical therapy office with symptoms associated with vertebrobasilar insufficiency (VBI) is very, very, very minimal.  VBI is an important diagnosis to consider, as many symptoms can mimic benign peripheral etiologies in our industry.

Most of the data in the physical therapy world on the incidence of VBI is after a manipulation, which is anywhere 1 in 20,000 to 1 in 1 million.  But I’m not talking about iatrogenic causes, but actual spontaneous events, which is what would most likely lead someone to come into your office.

The probability of this non-benign condition is higher if you treat neck pain and even higher if you treat headaches and dizziness.  We know the work by Lucy Thomas especially has shown in chart reviews that dizziness, headaches and balance/postural issues are high impact symptoms of VBI.  Her recent work has confirmed the previous work by Alan Taylor & Roger Kerry from mid-2000s.

As differential diagnosis machines, we need to be to be able to effectively address neuromusculoskeletal conditions.  Clinicians should always have VBI as a small nugget in the back of the head as quite frankly, a central cause of headaches, neck pain or dizziness is not one of which we should back down lightly in our knowledge of differential diagnosis.

cervical vertigo, cervicogenic dizziness, manual therapy, cervical spine
Rights Reserved: Harrison N. Vaughan, DPT, FAAOMPT

We have written in the past (here, here, and here) about ruling out vascular sources that leads to these symptoms in the past and even have written about the use of the HINTS examination to assist clinicians in differentiating between central and peripheral causes of dizziness.  There has been a significant spike of power behind simply looking at blood pressure and we know these tools are highly necessary before doing any type of mechanical testing, such as the VBI test.

Another tool that is not spoken much about, but we have in our algorithm to rule out spontaneous disorders, is the use of biomarkers.  The use of biomarkers for differential diagnosis is used for other conditions (such as temperature for a fever) but not spoken of much in the physical therapy world.

The use of blood biomarkers for differential of VBI was spoken of over 20 yrs ago quite but to my readings of the literature in the past decade, I haven’t seen much about it until now.  A recent study in 2020 out of South Korea by Sohn et al brought this information back to life and I want to share with you all.

The authors looked at blood biomarkers to examine differential diagnosis in 2 groups — 1 is central vertigo (CV) and 2 is peripheral vertigo (PV).  We know VBI would be under central vertigo.  The patient also went under full neurology examination including having MRA and CT scan.

Here is what they found:

 Serum NSE and S100β levels are significantly higher in patients with CV, such as occurs with posterior circulation ischemic stroke or vertebrobasilar insufficiency. S100β and NSE may serve as serum biomarkers for differentiating between CV and PV in patients with acute-onset vertigo.

Take home points

First, I take this information as another recommendation I could make to the medical staff to obtain, in addition to full neuro examination including MRA, if I suspect central vertigo through my clinical examination.

Secondly, I take this information as another non-mechanical test (such as prior to cervical ROM and VBI testing) that could be achieved before placing undue stress on the blood vessels that could take a spontaneous dissection to a full dissection.  We all know how this is usual what happens and what has given manipulation such a bad name in the past.  We had a great article we wrote awhile ago about this happening NOT from manipulation, but from cupping and massage.  I think this can help you understand this concept more.

Thirdly, I know we can’t order or have ability to obtain blood biomarkers, nor understand how to read the results professionally.  Therefore, I take this type of study as a physical therapist with confirming the already established Optimal Sequence Algorithm for diagnosing not only Cervicogenic Dizziness, but for Cervical Artery Dysfunction.


Cervicogenic Dizziness Course

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

 

5 charts showing why therapists should learn about Cervicogenic Dizziness

Cervicogenic Dizziness, Cervical Vertigo

Cervicogenic Dizziness, Cervical Vertigo,

Science begets more science.

That is how we continue to advance and propel ourselves forward in neuromusculoskeletal rehabilitation.

For over the past decade, we have treated dizzy/vertigo and neck pain disorders.  We have allowed guidelines and clinical expertise guide us to treat these conditions when presented to us independently.  More memorable to us is what we have created together (orthopedic and vestibular therapist) when these symptoms are combined or overlap.  We call this our Physio Blend.

Most clinicians can agree that these symptoms are combined more often than simply independent entities but difficult to “prove” via research.  During our teaching, we discuss the research on the double entity — i.e. multiple systems contributing to symptoms — but today, we present to you 5 charts showing why neck pain and dizziness are correlated in research.

1. Concussion Research

 

Concussion Research (Source: Pubmed) from 1990-2019)

Concussion, in general, has by far had the greatest attention in the medical industry in the past few years.  As you can even see from the graph above, a huge spike starting occurring around 2012 and has skyrocketed over 300%.  For those in the clinic treating Post-Concussion Syndrome, you are well aware of the multiple systems (and professionals) needed to treat the individual entirely.  Read more about this topic from a previous post here and here.

2. “Neck Pain and Dizziness” Research

“Neck Pain and Dizziness” Search from 1990-2019

When I searched for the combined phrase, “Neck Pain and Dizziness”, I did not expect to find such a spike in research over the past several years.  Obviously this does make sense clinically as this is what we see (and teach), but good to see the research catching up.  For you all in the clinic, I know you see an improvement in neck pain patients when treating the neck and could also see a spike in improvements with neck pain when treating the vestibular system. Read more about this topic from a previous post here and here.

3. “Neck Pain and Vertigo” Research

 

“Neck Pain and Vertigo” Search from 1990-2019

Vertigo as a symptom is not nearly as correlated clinically as dizziness as a symptom when speaking of Cervicogenic Dizziness, but can’t deny the overlap of terms in the clinic and research.  Interesting there is a big spike from 2017 to 2019 with articles (almost double) with this phrase.  We have written about the controversy between professions over this topic and you can read more about it here.

4. Cervical Vertigo Research

Cervical Vertigo Search from 1990-2019

Cervical Vertigo should be becoming more antiquated of a term and you can certainly see a drop in this phrase in the research starting in 2014.  One of our most popular articles discusses this topic and you can read more about it here.

5. Cervicogenic Dizziness Research

Cervicogenic Dizziness Search from 1990-2019

You may wonder why we actually left the phrase, “Cervicogenic Dizziness” for last in this article considering this is the main expression or our combined knowledge.  You can see from the chart above that this is the least common terminology and nothing was found of it prior to the year 2000 when Diane Wrisley’s most famous article came out.  I think you can take out of this chart is that if you want to research an article, you need to look at multiple search items and not limit yourself to one phrase.  This is how we created the research behind our Physio Blend — by examining the works of the osteopaths, acupuncturists, chiropractors, physios and surgeons.  We really need to favor conservative care for this condition and you can read more about this topic here.

 

So there you go!  You can see a trend towards having knowledge of multiple systems to fully treat someone with dizziness, vertigo and neck pain.


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

A brief overview of Cervical Dizziness

Cervicogenic Dizziness, Cervical Vertigo

Cervicogenic Dizziness, Cervical Vertigo,

What is Cervicogenic Dizziness?

Physiologically, cervical dizziness is explained by the presence of connecting fibers between the somatosensory system of the cervical spine and the vestibular nuclei.  Through these fibers, afferent somatosensory information from the cervical spine can alter the spontaneous firing rates and synchrony of firing among neurons in the vestibular nuclei.

When the somatosensory influence turns out to be a major influencing factor compared to the otolith, semicircular and optical stimuli, the symptoms can be called cervicogenic dizziness.  When the compensation fails from these systems, a vestibular syndrome can occur. The symptoms are usually described as dizziness, lightheadedness, unsteadiness or drunkeness.  True vertigo is rare and typically not a symptom of cervical origin. 

Overall, we can consider these patients to have postural instability and altered head on neck awareness.  The practical consequences to the patient may be dizziness in the short term and imbalance and falls in the long term.  

How do you diagnose Cervicogenic Dizziness?

Symptom provocation is initiated following active or passive neck torsion, typically in a cervical extension or rotation manner. Cervicogenic Dizziness has a different nature and behavior compared to benign paroxysmal positioning vertigo (BPPV) and vertebral-basilar insufficiency (VBI) and it is generally not associated with neurological signs and symptoms.

Several reasons have been described for altered sensorimotor input from the cervical spine.  These usually include acute or chronic neck pain, stiffness and trauma.  Trauma is typically following a fall, whiplash-associated disorder and/or concussion.  Other reasons can be due to accompanying decreased mobility and cervical muscular tone secondary to a peripheral dysfunction.  Due to these factors, cervical dizziness can be described as a single entity or double entity condition.

How do you treat Cervicogenic Dizziness?

Non-invasive cervicothoracic, orofascial and/or shoulder girdle treatment is the best recommendation for initial management of cervicogenic dizziness.  Statistically relevant improvements from manual therapy and exercise in the immediate, short-term and long-term has been found in clinical research to decrease frequency of dizziness, intensity of dizziness, intensity of pain and positive changes on functional outcome measures.  Systematic reviews over the past 15 years have consistently concluded positive changes from joint mobilization and/or manipulation.

Improving neck mobility, decrease viscosity and stiffness, and dampening pain is the first course of action of treatment.  Secondarily, improving eye–head kinematics and gaze accuracy by voluntarily increasing head movement amplitudes and head contributions to gaze saccades may lessen symptoms, improve stability, and reduce falls (Johnston et al 2017)

The improvement of symptoms can be attributed to restoration of cervical mobility and motor control with head on neck orientation.  Since two-thirds of extra cranial vestibular signals are from the cervical spine, achieving balance of proprioceptive and nociceptive input to the central nervous system from the joints and muscle spindles is key management.  This appears to achieve balance in afferent input from multiple systems to the vestibular nuclei that aid in the complex nature of postural control.  Therefore, initially, the disappearance of some of these symptoms is related to changes in neural activity in the vestibular nucleus from changes in the afferent information from the cervical spine.

Do patients with Cervicogenic Dizziness get better?

Patients generally have a very good prognosis, especially if simply a single entity sub-diagnosis.  A double entity sub-diagnosis will require further assessment and treatment procedures to see response in symptoms to then provide the prognosis.  We usually can provide a more detailed analysis after a few sessions to see how the patient responds to multiple therapeutic approaches.


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

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

Sign up for more emails on this topic by clicking here

Authors

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Can Botox help Cervicogenic Vertigo?

Cervicogenic Dizziness, Cervical Vertigo

Cervicogenic Dizziness, Cervical Vertigo,

Can Botox help Cervicogenic Vertigo?

We recently read with interest a case report in 2020 by Dr. Odderson in the Journal of Clinical Neuroscience describing the resolution of Cervicogenic Vertigo using botulinum toxin (botox).

Albeit a short literary piece, Dr. Odderson provides sufficient information with cause/effect relationship of success using botox for Cervicogenic Vertigo after failed physical therapy, course of prednisone and two cervical epidural steroid injections.

Now before you go off and recommend botox for your dizzy and neck pain patients, let’s highlight 6 clinical characteristics about the patient as described in the study (in bold) and OUR impression (not bolded):

  1. This patient was also diagnosed with cervical dystonia by EMG. 
    • Anyone who has treated a patient with cervical dystonia knows it is not straightforward cervical case, especially if adding on 10 years following a traumatic event and multiple system involvement to cause dizziness.
    • I have actually recommended botox for cervical dystonia patients (which is also recommended in the literature) if no success with other conservative measures.  This pathology can be challenging and with it now in the literature, the typical signs and symptoms may not be as traditional as we first thought.  This takes us to other characteristics.
  2. She had onset of symptoms with full cervical rotation to the left
    • Over 2/3 of patients with Cervicogenic Dizziness have symptoms with cervical extension, which was not mentioned in this article.  Rotation is second most common, such as in this case and some of our cases too.
  3. She had symptom reproduction at times when lying in bed.
    • Cervicogenic Dizziness provocation is more positional, not positioning.  Meaning, positional movements (such as ROM as described above) brings on symptoms with minimal latency and fatigues if provocating maneuver is reduced.
    • Potentially, with the amount of stenosis as described in the case report, would create more of an upper cervical extension moment, placing undue compression on the upper cervical spine (and oblique capitis superior that was prominent in this case).  We see headaches and neck pain > dizziness arise with this position.
  4. The patient would, at times, have to lie down due to symptoms so bad it would make her nauseated.
    • It is a general rule that Cervicogenic Dizziness is not as “functionally limiting” or “severe” as a peripheral vestibular condition (such as BPPV).  Even Susan Reid’s 3 question clinical prediction rule helps us as clinicians consider symptoms that “keep the patient more at home” as NOT to be cervical in nature vs other causes.
    • Again with the cervical dystonia present, the amount of abnormal afferent information to the vestibular nucleus could have significantly altered postural control and head on neck awareness to make the patient this ill.
  5. The cervical vertigo presented with episodic bouts of dizziness, where the environment would move for her.
    1. It has been well-established in the literature (we have even written several posts on it too) that someone with dizziness arising from solely the cervical spine, or extra-cranial origin, is not described as the room spinning (i.e. vertigo).
      • I cannot say I am an expert at cervical dystonia, but possible the altered afferent proprioceptive projections from cervical and nuchal musculature (C1-4) is enhanced in this population and significantly overloads the signals to the vestibular nucleic complex.
    2. Anyone in neuromusculoskeletal physical medicine avoids “never and always” and again, this case could debunk our typical descriptors of dizziness in this population.
      • With this being said, we are moving away from descriptors and move towards timing and triggers for our dizziness diagnosis as we describe in our course.
  6. The patient “failed” physical therapy
    • Ah, as physical therapists, we hate this term!  It’s like saying, “doctoring failed” or “nutritioning failed”, etc You get the point.
      1. Yes, prednisone and cervical injections failed too — but we can all agree that there is a certain dosage, location (by mouth or location in spine) that is specific to these procedures, thereby, knowing its cause / effect action.
      2. We have a phenomenal profession don’t get me wrong, but we do know that not all physical therapy is created equal.  Questions arise, such as:
        • Did this patient receive manual therapy?
        • If so, what type of manual therapy?
        • Did this patient receive a more advanced clinical reasoning management approach or general stretching program to the upper trapezius? (Our most popular article…)
        • Was the therapist more of a “vestibular” therapist?
          • Many (but not all!) of vestibular therapists don’t really address the cervical spine.

Flexion Rotation Test, AA, C1-2, Cervicogenic Dizziness, Cervical Vertigo

Lots of questions remain for me for but overall a great case study here!  I really enjoy reading these as it helps professional allies come together to work mutually to help these patients.  I want my physical therapy colleagues to know about the positive effects of botox for certain patients and for my medical colleagues to realize these impressions (numbered 1-6 above) of how a physical therapist thinks!


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 cervical vertigo in an ENT office?

Cervicogenic Dizziness, Cervical Vertigo

Cervicogenic Dizziness, Cervical Vertigo,

The prevalence of Cervical Vertigo can depend on many factors.  One of the major factors that determine prevalence is if a study looks at this diagnosis as a single or double entity.

This basically differentiates if the origin of dizziness is

Single entity: solely from cervical origin

Or if the origin is a double entity — meaning the cervical spine is a component of the symptoms but the patient also has dysfunction of the peripheral (i.e. BPPV) or central (i.e. concussion) system.

Read a previous blog that we wrote in this topic here and specifically for concussion here.

We also find that the prevalence of Cervical Vertigo is different between different professions.  What do we mean by this?  Simply put…if you are a rehabilitation professional (i.e. osteopath, chiropractor, physical therapist), then you have the capability and skills to intervene to the cervical spine more than say an allopathic medical provider (i.e. family physician, ENT, neurologist).

We have written about this topic in a Chiropractic office in the past.  You can find the blog here.

Therefore, this takes us to the title of this post:

How common is cervical vertigo in an ENT office?

To answer this, we refer to a 2019 retrospective review of a private ENT office by Polaczkiewicz L & Olszewski J analyzed the most common causes leading to dizziness, vertigo and balance.  Here are the individual diagnosis results from highest to lowest percentage:

35.86% = vestibular disorder

18.9% = benign paroxysmal positional vertigo (BPPV)

16.12% = mixed vertigo

5.42% = cervical vertigo

5.1% = Méniére disease and its suspicion

3.78% = vertigo and dizziness of central origin

2.8% = vascular vertigo

2.3% = vestibular neuritis

1.32% = post-traumatic dizziness

0.16% = cerebellopontine angle tumors

For the purpose of this blog and our interest in Cervical Vertigo, you will find from the bolded percentage above that these authors found that Cervical Vertigo is top 4 diagnosis over the 6 period span in their medical review.

Manual Therapy to the Neck for Cervicogenic Dizziness Treatment

5.4% is much less than the 25% that Vindengi et al 2019 found in the Chiropractic field via online survey but makes sense right.  If someone was having more neck pain and disturbances, wouldn’t they seek out manual medicine vs allopathic medicine?

This percentage is slightly lower than the 8-10% of general prevalence of single entity of Cervical Vertigo that is found across the field but this is one private practice and not general practitioner office, but ENT.

Nevertheless, this is an interesting piece of literature to bring to your local ENT professionals as if they do find cervical origin, wouldn’t they want someone who is trained in treating this to help their patient?


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

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

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