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Vestibular Nucleus: The Eye of the Hurricane

Cervicogenic Dizziness, Cervical Vertigo

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

A key phrase that is often taught for focus is,

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

So, how does this relate to Cervicogenic Dizziness?!

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

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

Cervicogenic Dizziness, Cervical Vertigo,

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

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

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

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

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

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

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

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


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

Pertinent to this blog post, the 1st day includes the “Optimal Sequence Algorithm”, a multi-faceted physiotherapist approach to the assessment of Cervicogenic Dizziness, which includes the appropriate ruling-out process and cervical examination of the articular and non-articular systems. Also pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

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

Authors

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

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We REALLY need this study to favor physical therapy over surgery

Cervicogenic Dizziness, Cervical Vertigo

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

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

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

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

Photo: Li et al 2019

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

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

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

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

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

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

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

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

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

AUTHORS

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

Importance of deep cervical extensor muscles in Cervicogenic Dizziness

Cervicogenic Dizziness, Cervical Vertigo

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

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

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

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

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

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

RCPmi dissection.
Photo courtesy of Yuan et al 2017

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

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

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

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

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


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

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

AUTHORS

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

This is why you should perform Cranial Nerve Exam

Cervicogenic Dizziness, Cervical Vertigo

 

Cranial nerve testing is BORING!

In entry-level physical therapy education, I remember learning (well, memorizing at the time) the cranial nerves.  We did everything we could to remember it including the most entertaining mnemonics 🙂

It never “stuck” with me to include this in daily clinical practice examination until I followed through with my Fellowship Program and specifically used it in a manner to rule-out conditions, specific conditions at that.

I enjoyed reading an article entitled, “Extracranial internal carotid artery aneurysm presenting as symptomatic hypoglossal and glossopharyngeal nerve paralysis” in The Journal of Laryngology & Otology in 2004.  Even though “old” in today’s standards for evidence-based practice, I want to point out the concepts that arise from the clinical reasoning and its relationship to Cranial Nerves and the Internal Carotid Artery. 

One concept I always push in our Cervicogenic Dizziness Course is that we need to be vigilant on the entire cervical vascular system and not just screening for Vertebrobasilar Insufficiency.  This ultimately means we need to know about signs/symptoms and clinical characteristics of disorders to the Internal Carotid Artery.  We can therefore, make sure we rule-out other sinister conditions to then aid in ruling-in Cervicogenic Dizziness as the diagnosis.

Cervical Vertigo. Cervicogenic Dizziness.
All Rights Reserved. Cervicogenic Dizziness. Optimal Sequence Algorithm. Integrative Clinical Concepts.

Just as described in our Optimal Sequence Algorithm, the first step prior to even assessing the vascular system, especially any mechanical disruption, is to go “back to basics”.

This involves initially examining the cranial nerves, especially the ones that may be affected first in a patient presenting with internal carotid artery dysfunction.

Cervicogenic Dizziness, Cervical Vertigo

A negative finding on cranial nerve examination is one of the presenting clinical findings that led the team in this paper to perform an ultrasound on the neck and then refer for MR imaging.

You may ask what led to performing cranial nerve exam. Here you go:

Here are the paper highlights:

Subjective

  • After a patient went to chiropractor for 3 visits 1 month prior, she self-admitted to ENT office for painful swelling in jaw .
  • She had several bouts of dizziness associated with turning her head to her left.
  • She had bouts of light-headiness.
  • She also developed loss of hearing in her left ear.

Objective

  • Odd sensation with swallowing
  • Marked tongue deviation to the right side with tongue protrusion
Cervicogenic Dizziness, Cervical Vertigo
Cervicogenic Dizziness Course

So how does this relate to Cervicogenic Dizziness?

  • The subjective findings above could mean mechanical or non-mechanical source of symptoms but objective findings indicate a cranial nerve palsy response to cranial nerve testing (specifically hypoglossal and glossopharyngeal).
  • Patient could have self-admitted to a physical therapy office instead of ENT, so ultimately we need to be able to fully examine someone with initial thoughts of non-mechanical symptoms unless proven otherwise.
  • Positional dizziness, such as turning head to the left, are typical symptoms associated with the diagnosis of Cervicogenic Dizziness.
  • Lightheadiness is a typical symptom associated with the diagnosis of Cervicogenic Dizziness.
  • She had a recent minor trauma, which in this case, was a trip to the chiropractor with assumption of a manipulation performed.
    • Instead of seeing another clinician, she could have simply had a recent minor trauma from looking up, played golf, or even had a concussion or in a car accident.

Even though the authors suggest there was a correlation with chiropractic manipulation prior to patient seeing ENT, it cannot be proven that the procedure was the cause of her cranial nerve palsy. In fact, her attacks of lightheadiness and pain worsened after initial visit to the ENT, who prescribed anti-biotics!  Another post on this coming in the future.  

Even a recent blog post from these authors describe vascular insult cases after massage and cupping therapies.

Nevertheless, we recommend clinicians screen appropriately with subjective and objective examination procedures, especially if someone is presenting with symptoms of lightheadiness, dizziness and/or vertigo.


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

You need this to recover from peripheral vestibular deficits

When most physical therapists think of peripheral vestibular deficits, we typically think of isolation of a condition, such as BPPV.  This, at least since 1926, involves canalith repositioning testing via Dix-Hallpike manuever and treatment, since early 1980s, with Epley Manuever.

A large and sometimes missing link is that individuals with unilateral peripheral vestibular deficits acutely constrain their head movements relative to their trunk to reduce symptoms of oscillopsia, dizziness and nausea.  These altered movement patterns can result in the loss of normal decoupling of head motion from trunk motion while walking and potentially have a less efficient gait pattern and postural activity tolerance.

For the therapists who work in inpatient, home health setting and even outpatient rehabilitation centers, we typically examine dynamic gait tasks and even though not as high priority of movement patterns to a generalist assessment, these movements significantly impact head and trunk requirements.  As you can see from Table 1 below from Paul et al 2017 paper, entitled “Characterization of Head-Trunk Coordination Deficits After Unilateral Vestibular Hypofunction Using Wearing Sensors”, the Functional Gait Assessment, Timed Up & Go Test and 2-minute Walk Test have large influence of head and trunk rotation influences.

Cervical Vertigo, Cervicogenic Dizziness, Neck Imbalance,
Paul et al 2017

Even though this study examined deficits in gaze and postural stability of the head and trunk after surgically induced unilateral peripheral vestibular hypofunction, the physical therapist can relate the head and trunk movements required for any peripheral vestibular disorder and relate the impact of the cervical proprioceptive system in active movement of the head and trunk coupling moments.

You can see in the 3rd column on right above that yaw plane (angular rotation) of the head and trunk that relates to coupling of head and trunk rotation is necessary to accomplish these tasks.  Considering C1-2 (Atlanto-Axial Joint) is 50% of rotation of the cervical spine, this could be a significant limiting factor in your patient.  Read a previous post on how this joint restriction relates to Cervicogenic Dizziness. 

Paul et al 2017 concluded,

A key component to recovery from peripheral vestibular deficits is the regular exposure of head movements that may induce gaze and postural stability errors and therefore facilitate recovery.

If you are a trying to implement regular exposure of head movements but run into a wall of neck pain, restriction of range of motion or even lightheadiness associated with these movements, then our class of diagnosing and treating Cervicogenic Dizziness can be of benefit to you.  Most of our classmates think this class is mostly for post-concussive or whiplash patients; but I disagree that it can be even more important in reducing fall risk and improving movement patterns in the elderly!  The association of cervical disc disease and restriction in mobility of the cervical spine is by far more prevalent in society that trauma-based cervical conditions.

As Paul’s study arose in the literary works, another fantastic investigation by Julia Treleaven & colleagues out of Australia in 2018 suggests that neck pain subjects have difficulty moving their trunk independently of their head.  Her work on altered trunk head co-ordination in those with persistent neck pain indicates that tasks are performed more slowly with neck pain patients, which directly correlates to the speed and accuracy testing of gait testing through Functional Gait Assessment, 2-minute Walk Test and Timed Up and Go Test.

Even if you are not treating “dizziness or vertigo”, but are involved in reducing fall risk in patients in any setting, contact us to see if this course can help your patients.  As you know, the Home Health Physical Therapy industry is performing Vestibular Rehabilitation and continues to focus on Fall Risk Reduction.  A missing link of improving postural control and balance can be limitation to the upper cervical spine.  Specific diagnostic and treatment approaches are available to benefit your patients and continue to raise the bar of rehabilitation.


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

Deep Cervical Flexor Dysfunction with Cervicogenic Dizziness

Cervicogenic Dizziness, Cervical Vertigo

The deep cervical flexors (longus colli and longus capitis muscles) have received the greatest attention in the literature for addressing strength, endurance and motor control for cervical spine disorders.

There are numerous studies showing deep cervical flexor training groups show a significant improvement in pain, disability and functional improvement for several subgroups of mechanical neck pain. One of these subgroups is with dizziness from a cervical origin.

Exercise training should be focused to alter specific muscle impairment, especially deep cervical flexors. There are many ways to strengthen the neck and interesting ones to find on YouTube! Additionally, there are some tools (such as Chattanooga Stabilizer) that is common in a physical therapy office that can assist the clinician in helping a patient. However, these are not always available in a vestibular office or even home health visit (or quite frankly OUR office either).

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

One of the most common compensation patterns is overutilization of the sternocleidomastoid and anterior scalenes. If you are nonchalantly training the cervical spine (say…across the room as you work with other patients), the patient on the table may “think” they are training the deep cervical flexors but instead may just be perpetrating superficial cervical muscle activity. Or worse, the patient may just be “picking” at their pain in the posteriorly cervical column, especially if the sensation is in the upper cervical spine.

Cervicogenic Dizziness

 

There are many pieces of literature that provide a multi-modal treatment approach for CGD (Jaroshevskyi 2017, Karlberg et al 1996, Wrisley 2000, Hansson 2007, Hansson et al 2006, Bracher 2000, Galm 1998, Schenk 2006, Collins & Misukanis 2005).  However, it is interesting that the leading highest level evidence through multiple randomized-control trials (Reid et al 2008, 2012, 2014, 2015) shows that an isolated, specific and less time consuming manual treatment can be effective for short and long term results.

We do recommend a manual therapy approach first, followed by graded exercise and/or vestibular approach. No matter how you perform the re-training any motor control deficits of the cervical spine, we recommend that you “teach the patient to feel it where they should”, and even more importantly, “teach them where they should NOT feel it”.

Cervicogenic Dizziness

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 Vertigo and Dizziness come from Neck Muscles?

Cervicogenic Dizziness, Cervical Vertigo

When a clinician thinks of dizziness from the neck, or Cervicogenic Dizziness or Cervicogenic Vertigo, typically the zygapophyseal joints come to mind as a proprioceptive and nocioceptive abnormal afferent input.

In fact, most authors agree that the following order, C1-2, C2-3, C0-1 and C3-4, are the most often influenced in cervical symptoms following mTBI due to high influence of proprioceptive activity from these levels.

Moreover, the muscles of the posterior cervical spine, the suboccipital musculature, have an abundance of muscle spindles and are high in mechanoreceptor concentrations.  These deep, short intervertebral neck muscles are also typically involved in proprioceptive and nocioceptive abnormal afferent input.

Interesting enough, a recent case report in 2018 and literature review appeared in Medicine Journal with title, “Vertigo caused by longus colli tendonitis“.

For us with anatomical training, we know the longus colli is anterior to the cervical spine and doesn’t typically come to mind with proprioceptive activity.  However, we do know it has proprioceptive distribution (albeit less) and commonly injurious after whiplash injuries.

This case report of a 38 year old male with vertigo arising from longus colli tendonitis is interesting as there was no description of trauma (other than running).  The authors hypothesize that the swollen longus colli muscle stimulated the cervical sympathetic ganglia, resulting in symptoms, which were then alleviated by corticosteriod injection and acupotomy.

The hypothesis of Cervicogenic Dizziness as a cause of vertigo / dizziness has a strong trend towards the proprioceptive pathogenesis and less of a trend towards sympathetic dysfunction.  In fact, stimulation of the cervical sympathetic ganglia is now becoming discarded in the literature.

This case report, albeit n=1, brings back to life this hypothesis and although rare, could be a cause of vertigo in your patients when all other medical causes are ruled out.  Even though in this report by Shen et al 2018 found 0% of previous cases (n=278) exhibited symptoms of vertigo or dizziness, there could be some anatomical variations in the longus colli muscle and if the perfect storm was created (i.e. trauma, stress, weakness, etc), the individual could be symptomatic.

I would liked to have seen conservative treatments (i.e. physical therapy) introduced prior to invasive procedures but nevertheless, was successful for the patient and worth a read.


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 1st day includes the “Optimal Sequence Algorithm”, a multi-faceted physiotherapist approach to diagnosis of Cervicogenic Dizziness while ruling out other causes.

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 Vestibular Rehabilitation Improve Dizziness After A Concussion?

Cervicogenic Dizziness, Cervical Vertigo

Reidar Lystad and colleagues in 2011 published a critical systematic review entitled, “Manual Therapy with and without Vestibular Rehabilitation for Cervicogenic Dizziness: A Systematic Review”.  I say it is critical because of the following conclusion,

There is moderate evidence to support the use of manual therapy, in particular spinal mobilisation and manipulation, for cervicogenic dizziness. The evidence for combining manual therapy and vestibular rehabilitation in the management of cervicogenic dizziness is lacking. Further research to elucidate potential synergistic effects of manual therapy and vestibular rehabilitation is strongly recommended.

I highlighted a particular important outcome of the systematic review in bold above.  Basically, just 7 years ago (at time of writing this blog), we do not have the highest level of evidence telling us we should perform vestibular rehabilitation on patients diagnosed with Cervicogenic Dizziness!

In the era of evidence-based practice, we know this is just one leg to Sackett’s stool; but can’t deny the power of a systematic review!

One thing we point out in our Cervicogenic Dizziness Course is if you delve into this review, you will note that there are no studies that indicate use of Vestibular Rehabilitation in Cervicogenic Dizziness, therefore, of course the evidence is lacking!

Cervicogenic Dizziness, Cervical Vertigo
http://www.iccseminars.com

Over the years as medicine and practice knowledge grew, we have been able to add onto this statement with a Randomized Control Trial, a Retrospective Chart Review and an Exploratory Study  Even though only three articles, this is better than none back in 2011!  This was exposed in a recent article in 2018 entitled, “Vestibular Rehabilitation Therapy Improves Perceived Disability Associated with Dizziness Post-Concussion” to express there is level 2 and level 3 evidence supporting the use of vestibular rehabilitation to treat patients suffering from dizziness post-concussion.

I would also add, even though not specific to post-concussion, Jaroshevskyi’s work in 2017 finding the following conclusion:

The multimodal approach using manual therapy in combination with acupuncture and vestibular rehabilitation showed the maximum therapeutic effect on elimination of musculo-tonic disorders, reduction of a pain syndrome with a complete regression of vertigo and postural instability.

The last study is one I want to bring to light and expose that ultimately, to achieve maximal therapeutic benefit, we CAN’T limit ourselves to just performing manual therapies OR vestibular rehabilitation for a complex disorder such as Post-Concussion Dizziness, Cervical Vertigo or Cervicogenic Dizziness.

We should, and need to, continue to blend the two specialities so patients can achieve the best of the best treatments to maximize recovery, decrease symptoms, and return to sport.

This is why Drs. Vaughan created the Physio Blend for treatment of Cervicogenic Dizziness — it is the most researched and skillful approach to tailor to these complex cases.

If you are a Vestibular Therapist wanting to learn specific manual therapies or a Manual Therapist wanting to learn vestibular rehabilitation for your patients, this is the course for you.


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

2 manual techniques are better than 1 for Cervicogenic Dizziness

Cervicogenic Dizziness, Cervical Vertigo

A 2019 randomized control trial entitled, “Combined use of cervical headache snag and cervical snag half rotation techniques in the treatment of cervicogenic headache” by Mohamed et al has caught my attention.   I enjoyed reading this study due to not just having 2 randomly assigned groups, but it had a 3rd group ===> one of which combined techniques from the first 2 groups to see if patients get better results vs just determining if a single procedure provides pain relief and functional improvements.

After 3 sessions per week for a month, here is conclusion:

Results of the study showed a significant improvement in post-treatment scores of all measured variables within groups and among the groups with the combined groups showing the greatest improvement.

Table from Muhammed et al 2019
Post-treatment NDI was significantly lower in Group C compared to the other two groups (p<0.001) and was comparable in groups A and B (p=1.000). The percentage drop of NDI was significantly higher in Group C compared to the other two groups (p<0.874), but the magnitude of NDI drop was comparable between Groups A and B (p=1.000, Table 2).
Table from Muhammed et al 2019
HIT-6 was comparable in the three groups (p=0.936), and decreased significantly after treatment in all the three groups (p<0.001 for all comparisons). After treatment, it became significantly lower in group C compared to the other two groups (p<0.001) and was comparable in groups A and B (p=1.000). The percentage decrease of HIT-6 was significantly higher in group C compared to the other two groups (p<0.001), while it was comparable between Groups A and B (p=1.000).

There you go — performing 2 procedures (very specific procedures in this case) yields better results than a single procedure – especially in Headache Impact Test and Neck Disability Index.

You may ask how Cervicogenic Headache (as was diagnosis in this case) relates to Cervicogenic Dizziness in this post — we know there are overlapping pathophysiology mechanisms associated with the afferent input dysfunctional theory but also specifically for this study, ALL the patients had a trigger of dizziness with onset of headache and cervical extension — a prime movement associated with diagnosis of Cervicogenic Dizziness.

Cervicogenic Dizziness, Cervical Vertigo,

Generally speaking, combined procedures are what most clinicians perform in the clinic.  This is due to multiple impairments (such as joint restriction, heightened muscle tone, motor control deficits, etc) are typically found in a patient suffering from cervical pain.  Randomized trials have to limit variables in order to make a correlation hypothesis so as clinicians “in the trenches” who are looking for the best approaches to manage our patients, reviewing the results of randomized trials have limitations.

Even though most aged clinicians in our industry are tired of the “comparison” model of different manual therapy techniques, I like how this study combined techniques for a 3rd group — one of which I personally see better improvements in the clinic vs a single procedure.  I’m sure all treating clinicians agree.

Interesting enough to the clinician, the Dizziness Handicap Inventory did not show a significant improvement in the combined groups compared to single procedures.  See table below.

Table from Muhammed et al 2019
Before treatment, DHI was comparable in the three groups (p=0.501) and decreased significantly after treatment in the three groups (p<0.001 for all comparisons). After treatment, it became significantly lower in group B compared to group A (p=0.018). It was comparable between groups B and C (p=0.869) and between groups A and C (p=0.269). The percentage decrease of DHI was significantly higher in group B compared to group A (p=0.035). It was comparable between groups B and C (p=0.720) and between groups A and C

This finding does not surprise me at all.  In my opinion, the pathophysiology behind Cervicogenic Dizziness is more complex than Cervicogenic Headache with more “moving parts”.  It may well explain that to improve Dizziness related function to highest degree, the clinician may need to combine joint procedures, soft tissue procedures (aimed at high muscle spindle locations) and sensorimotor training.

Cervicogenic Dizziness, Cervical Vertigo

This is how we approach Cervicogenic Dizziness, coming solely as a single entity but also combined entity (i.e. associated with BPPV, mTBI, concussion, whiplash, peripheral hypofunction, etc).  We do this through our Physio Blend — a solid mix of combined approaches with research from the Physical Therapy (Manual and Vestibular Rehabilitation) Chiropractic, Acupuncture, and Osteopathic Medicine.  We find that this is the ultimate combined approach for this more complex and “moving parts” diagnosis. 


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 

Can you get a concussion from impact to the chest?

Typically when someone thinks of a concussion, a picture below comes to mind.

But, we also know sport-related concussion is just one type of injury that is associated with the diagnosis of concussion, or mTBI.  Prior to the recent build-up of information and data on concussion in sport over the last several years, we would treat similar symptoms in patients presenting with whiplash-associated disorders.

So, for those us treating whiplash, this type of image usually comes to mind.

One impact approach that typically doesn’t come to mind, but could potentially be more prevalent (although may require twice the rotational velocity) in contact sports (especially with changes in tackling rules) is the biomechanical response to the cervical spine from primary impact to the chest.

Potentially a picture like the one below can come to mind.

Instead of just helmet-to-helmet collisions, we can’t forget impulsive force transmitted to the head from a direct blow somewhere else.  This is in the definition from the 2012 consensus statement and considering the acceleration strain placed on the head and neck with this type of impact, we don’t want to forget this mechanism and potentially rehabilitation methods with this type of contact.

A recent study by Jadischke R et al in 2018 examined the biomechanical response and strain of the upper cervical spine and brainstem from chest impact in their study entitled, “Concussion with primary impact to the chest and the potential role of neck tension”.

Even though chest impact collisions causing concussion place lower stress on the neck, the authors did find that neck tension or strain along the axis of the upper cervical spine cord and brainstem is a possible mechanism of brain injury in concussion.

Cervicogenic Dizziness, Cervical Vertigo
http://www.iccseminars.com

Don’t always imply a neck injury results in a brain injury, but also don’t imply lack of direct head collision means less stress to the cervical spine.  You may just be missing a key component in manual and/or sensorimotor rehabilitation to get maximal results in your patients.


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