Cervicogenic Dizziness – the data needs more data!

Cervicogenic Dizziness, Cervical Vertigo

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

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

Hegedus, Wright & Cook 2017

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

If only it was that easy.

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

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

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

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

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

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

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

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

Sign up for more emails on this topic by clicking here

Authors

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

 

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Cervicogenic Dizziness is FINALLY here!

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

I don’t think you’ll be let down as our manuscript (included with each course) has—
> 60,000 words
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—all in the ultimate package to diagnose (including ruling-out) competing disorders through the Optimal Sequence Algorithm and evidence-based treatment approach of manual therapies and sensorimotor training through the Physio Blend.

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

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

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

Harrison

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

Cervicogenic Dizziness, Cervical Vertigo

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

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Cervicogenic Dizziness, Cervical Vertigo, Concussion, Whiplash


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

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

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

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

Should you Manipulate a patient with Cervicogenic Dizziness?

Cervicogenic Dizziness, Cervical Vertigo

vertigo

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

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

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

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

bolton

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

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

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

 

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

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

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

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

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

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

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

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You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the author and his wife, a Vestibular Specialist, teach a 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.  

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

Authors

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Physical Therapist at In Touch Therapy, South Hill, VA

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Vestibular Physical Therapist at Drayer Neurological Clinic, Raleigh, NC

 

Cervicogenic Dizziness Course – Sale ends July 5!

Cervicogenic Dizziness, Cervical Vertigo

Cervicogenic Dizziness, Cervical Vertigo,

Happy July 4th to all my readers!

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

Use code: Vista25 for $25 off 

or if signing up with colleagues (3 or more)

Use code: Group for $50 off each

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

Use code: STUDENTCGD for 70% off!

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

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

 

 

Cervicogenic Dizziness – Excerpt from Maitland 1979

Cervicogenic Dizziness, Cervical Vertigo
Courtesy: http://www.imta.ch/

I am a big believer of standing on the shoulders of giants.  Even though I am not “Maitland trained”—I use his constructs of concordant sign, sensitivity/irritability and several other clinical reasoning aspects in my examination and treatment approaches.  You cannot deny the impact he had on our profession.

I am reaching a decade now (old man status!) of treating in clinical practice and feel like I am seeing more and more that our predecessors are being put down, bashed, exonerated by writings and teachings of that time.   Maybe this is not everyone of course, but through the pits of social media, the bubble is expanding.  I am all about growth and science, but the concepts and principles behind assessing and treatment can still stand strong.  I always remember this foundation and add research on top of it—-to make things positive overall for us, keep reading and pounding out knowledge as the PT profession continues to grow as the best team in musculoskeletal conservative care with updates in research as the “why” of “what” we do is better explained.

Remember—it is always easier to critique than create.

We build off of each other and grow with decades of research, clinical practice and self reflection.  The way I see it—the time line of growth and education is not linear, but builds off like tree rings.

With that being said, it brings me to this excerpt from Maitland in 1979 about differentiating dizziness from arterial dysfunction (i.e. vertebrobasilar insufficiency) to cervical spine dysfunction.

Cervicogenic Dizziness

Of course by just reading this, we can mock the lack of clinical metrics behind this thought process (where are the sensitivity and specificity values!?), where is the research citation, how many of your dizziness folks can just go and lie prone??—- However, it is a concept based off of standardized thought processes in our field—-looking at effects of gravity, loaded/unloaded positions, reactions in latency and duration of symptoms, etc.

I would second guess this thought process by saying first we need to evaluate blood pressure, heart rate and appreciate the entire haemodynamic system!  We need to do a thorough screen prior to putting the neck at a risk for mechanical thrombus if the patient walks in with a spontaneous dissection!  We need to rule out a higher probability of dizziness through other benign conditions, such as through a canalith repositioning manuever!  Bam Bam Bam!

The previous paragraph is partly what I teach in my Optimal Sequence Algorithm to diagnose Cerviogenic Dizziness. I feel the components of the examination are the most sound, evidence-based approach based off of concept of diagnosis of exclusion, other reasonable reasons for symptoms, epidemiological data and prevalence/incidence of cervicogenic dizziness in the population.

Interesting enough….DeKlyne first spoke about the VBI test over 75 years ago and this wasn’t mentioned in Maitland’s work from 1979….Maybe he already knew the limitations behind it before we had clinical guidelines and clinical metrics.  I’m certainly glad he didn’t say drop the patient’s head off the edge of the table and see what happens.

Maybe its the history buff in me, but I enjoy looking back at these old articles.  They really can be considered blogs of modern times—-written by 1 author, 3-4 references and straight clinical interpretations.  Don’t give up on our past—but use it positively to build our future.

Sign up for more emails on this topic by clicking here

You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the 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 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.

Authors

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Physical Therapist at In Touch Therapy, South Hill, VA

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Vestibular Physical Therapist at Drayer Neurological Clinic, Raleigh, NC

Cervicogenic Dizziness – HINTS Exam

Cervicogenic Dizziness, Cervical Vertigo

The ability to differentiate between central and peripheral causes of dizziness went to another level by the work of Kattah et al in 2009.  The three-step bedside oculomotor examination was found to be more sensitive than early MRI diffusion-weighted imaging and really opened up the eyes (no pun intended) in regards to clinical diagnostic accuracy to the plinth vs imaging examination approach.

Since then, the works of Chen et al 2011 and especially the passion and agenda of several literary pieces by Newman-Toker, have further examined the diagnostic accuracy of the HINTS examination with highly powerful clinical metrics as a screening tool and potentially need for less imaging.

With a sensitivity ranging from 96.8% to 100%, the 3 step process is phenomenal for clinicians!  It definitely beats any of the PT so called clinical decision rules.

However, I wouldn’t hang my hat on this solely, especially if you’re a PT.  Three main points are made below:

Firstly, unless you have been trained in neuro-otology or neuro-opthalmology, then you may not be as reliable as these guys/gals.  Most of the studies involve an extensive training program and know what to look for in regards to a pathological sign.

Secondly, unless you pound out Direct Access (and most of us seeing dizziness aren’t….), then you aren’t seeing the patients under inclusion criteria set forth in the studies: which is typically a time frame of symptoms less than 7 days. 

Thirdly, all of the studies used a strict inclusion criteria—-resulting in studying moderate to high risk populations—ones with risk factors such as hypertension, diabetes, nausea/vomiting.  Therefore, if you are examining a low risk population, then the HINTS diagnostic sequence may not be as applicable or powerful in its accuracy.

HINTS is a fantastic sequence of objective clinical measures that individually, do not have much influence on a clinical decision, but combined, can be very powerful. Of course we do not rely on one test for diagnoses of other conditions, but a combination of tests/measures highly increases the diagnostic credibility.  I wrote about this with SIJ testing several years ago and more of common practice now in SIJ dysfunction diagnostics.

We teach the HINTS examination, but in context with other clinical features, risk factors and statements in the Subjective Examination and only in combination with other Objective clinical tests that are conceptual to cervicogenic dizziness.  This is what I do in my Optimal Sequence Algorithm.

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

If you want to learn more how to screen your patients and feel MOST confidently in addressing dizziness from a cervical origin, we have it all in our Optimal Sequence Algorithm.  Sign up here for more emails!

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 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.

Authors

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Physical Therapist at In Touch Therapy, South Hill, VA

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Vestibular Physical Therapist at Drayer Neurological Clinic, Raleigh, NC

Cervicogenic Dizziness – Controversial Entity between Professions

Cervicogenic Dizziness, Cervical Vertigo

There is controversy between professions.


Gonzalez and Palacios in 2001 wrote an article, “Cervical Dizziness: A Scientific Controversy” in Fisiotherapia Journal.  The final wording in the manuscript, albeit translated from Spanish to English, basically sums of the controversy that surrounds the diagnosis and treatment of cervicogenic dizziness in one sentence.

For practitioners of physiotherapy and manual medicine, the vertigo of cervical origin is almost unquestioned, treatable and solvable entity mostly, while for professionals otolaryngology and scholars of the vestibular apparatus and balance, their relationship remains hypothetical and in many cases questionable.

Gonzales and Palacios 2001


There is controversy between professions.


To those in the professions of manual medicine and rehab—osteopathy, acupuncture, chiropractic and physical therapy—the diagnosis and treatment of cervicogenic dizziness obviously occurs and can be present in many subsets of different populations.  To anyone who has dealt with this in their office, this seems to be a no brainer as results speak for themselves.  However, outside the manual medicines, including otoneurology and audiology; the diagnosis of exclusion stands concrete and likelihood of referring out is much less likely.  In fact, most of the literature denotes less than a 10% prevalence rate with dizziness from cervical origin and majority of studies consistently outside of the rehabilitation and manual realm do not list it at all under differential diagnosis.

Could cervicogenic dizziness be embellished in the manual medicine fields and neglected in the allopathic medical field?

cervical vertigo, cervicogenic dizziness
Cheever et al 2016

The question remains, what makes the incidence and prevalence so different between the professions?

Is it a business argument?  Obviously manual medicine and rehab can benefit from treating these patients, where medication and imaging does not work.

Is it science?  The diagnosis of dizziness from a cervical origin continues to be under debate and scrutinized (Brandt 1996, Brandt/Bronstein 2001).  There is a discrepancy in the pathophysiology, lack of diagnostic criteria including a well established clinical test or a specific laboratory test, and many other diagnoses can be a convincing alternative reason for symptoms.

Is it ethical?  With a lack of a true diagnostic test, unknown epidemiological data points and prognostic time line of improvement—could the manual medicine fields provide unethical treatments— scientific implausible treatments or even fraud?

Is it training?  Anyone in the physical therapy field knows the lack of training in the MSK field by physicians—we fuss about this all of the time.  We contend about their lack of knowledge to refer to us for even less controversial diagnoses.  You can imagine, considering even a small percentage of manual medicine that focuses on cervicogenic dizziness, that medical physicians do not have training or knowledge to refer out to us for this condition.  Just recently, Reneker et al 2015 found a distinct difference between professions regarding utility of clinically diagnostic tests for differentiating cervical and other causes of dizziness s/p concussion.  In fact, three tests, 1) passive joint mobilization, 2) palpation of cervical musculature and 3) joint position error testing were shown to have high utility to diagnose cervicogenic dizziness by PTs (62%, 53% and 47% respectively), but NONE of these were selected by a single neuro-otologist!


There is controversy between professions.


With such discrepancies between the philosophies and clinical approaches between the medical trades, it is no wonder there is never “cervicogenic dizziness / cervical vertigo” is not on a script.  We must meet on the same playing field here and see both sides of the argument with the manual and non-manual fields.

A fair result can only be obtained only by fully stating and balancing the facts and arguments on both sides of each question.

Charles Darwin

It can be challenging to go speak to physicians about this condition as we do not have the juice to provide in regards to evidence.  However, this is an emerging area of practice and the physical therapy field is gaining traction in RCTs by Susan Reid’s work to put more power to our trade.  With that being said, if you want to learn the evidence to present to physicians, either in the elderly, s/p concussion, s/p whiplash or some other head/neck insult—we got you covered because there is controversy between professions. 

 

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 entire weekend includes the most up-to-date evidence review from multiple disciplines to diagnose through the “Optimal Sequence Algorithm” and treat through the “Physio Blend”. 

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

Physical Therapist at In Touch Therapy, South Hill, VA

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Vestibular Physical Therapist at Drayer Neurological Clinic, Raleigh, NC

 

 

Cervicogenic Dizziness – should you treat the upper trapezius?

Cervicogenic Dizziness, Cervical Vertigo

trap

Simons and Travel 1999 describe myofascial pain (MP) as a common symptom usually caused by myofascial trigger points (MTrPs). The MTrPs in the neck muscles have been associated with a possible source of referred facial and cranial pain and could contribute to the nocioceptive activity occurring with Cervicogenic Dizziness.  The muscle most often affected with the presence of MTrPs in the neck region is the trapezius muscle,  specifically the upper fibers, and this is the most hyperalgesic muscle of the neck and shoulder (Sciotti et al 2001, Melegar & Krivickas 2007, Fischer 1987).  In fact, it is well established that treating soft tissue dysfunction of the upper trapezius is effective in the management of nonspecific cervical pain (Cagnie et al 2015,  Montañez-Aguilera FJ et al 2010Aguilera FJ et al 2009).

The authors of this manuscript consider addressing MTrPs in the descending fibers of the upper trapezius to be an appropriate treatment for individuals suffering from Cervicogenic Dizziness, however, it may be incomplete and suboptimal location to maximize potential outcomes.   It can have an influence on the functional relevance of the neck in its relationship with the cervico-collic reflex and vestibulo-collic reflex, but may not be a significant factor in modulation of its effects on head-in-space and head-on-trunk posture. All things considered, even though it is a popular location to stretch or treat manually, it may not be as much of a contributing factor of nocioceptive input into dysfunction of head on neck proprioception and self-motion perception.

The following two scenarios are the theoretical concepts to this impression:

  1. Relative Abundance of Muscle Spindles

Neck muscles are richly endowed with muscle spindles and contribute greatly to proprioception of the neck (Voss 1958, Cooper 1963, Kuklarni et al 2001Liu et al 2003).  The high muscle spindle density and the special features of the muscle spindles in the deep neck muscles allow not only great precision of movement but also adequate proprioceptive information needed both for control of head position and movements and for eye/ head movement coordination.

The number of muscle spindles in relation to muscle mass in a recent anatomical study by Banks RW 2006 confirms the greatest abundance is in axial muscles, including those concerned with head position.  The upper trapezius muscle is a high contributor of muscle spindles, but comparably, it is far behind suboccipital musculature, being rated #31 and along the same relative abundance as the adductor pollicis, extensor digitorum brevis, obliquees internus abdominus, omohyoideus, pronator quadratrus and extensor digitorum.  These muscles, due to their location, are of course not primary influence on head-on-neck proprioception.

So, based off of this information and overall thoughts on a patient’s adherence to a home program (keeping 5 exercises or less)— does stretching the upper trapezius, as described in the literature & pictured below, appear to be the most optimal treatment & one we should encourage with patients having cervicogenic dizziness?

trap
Minguez-Zuazo, et al 2016, Malmström et al., 2007; Schenk et al., 2006; Wrisley et al., 2000

2. Influence based off of points of attachment on occiput (from Dvorak J. Manuelle Medizin. 1988)

points of attachment

Based off of the cross section of the occipital anatomy shown above, you can question the influence of the upper trapezius, as compared to suboccipital musculature, on the effect of head on neck posture/proprioception.  The surface area of the upper trapezius is significantly less than other muscles of the cervical spine, especially short dorsal musculature of the upper neck.  Therefore, we must take into account the overall influence of the upper trapezius compared to other musculature to optimize patient outcomes and results to improve pain, joint position error and postural stability.

Thus, the theoretical constructs and literature review for the non-articular management of cervicogenic dizziness is unclear and still under scrutiny.   The application of soft tissue management at one location vs another can be determined through a thorough clinical reasoning process and assessment  The type of soft tissue intervention that is most optimal (i.e. dry needling, ischaemic compression, IASTYM, dry cupping, deep massage, etc.) is still under debate, but the authors of this post do feel the location of your intervention can make a difference.

Sign up here for more information on 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 prices and discounts.

Authors

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

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Physical Therapist at In Touch Therapy, South Hill, VA

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Vestibular Physical Therapist at Drayer Neurological Clinic, Raleigh, NC