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

 

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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.

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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

 

 

 

Re-Sensitization is where it’s at

central sensitization

Unless you’ve been under a rock as a clinician, the term ‘central sensitization’ should be in your vocabulary.  It has gained popularity through the cycle of pain science, especially over the past 5-10 years.  Even though it appears central sensitization is new and sexy, it is not a modern term, and to my knowledge, the seminal paper on it by Dr. Woolfe goes all of the way back to 1983. Much change and marketing has happened in this 33 year span, but even still, the thought process of this term has been around for centuries.

central sensitization

You can find 6 ways to Sunday to explain this phenomenon to your patients, which I do using my “Pain Cartesian Scale (here too).  I encourage you to find the best way to translate this to your patients in the context they need to understand.  My colleague and friend, Dr. Matt Dancigers, explains this better than anyone else I know.  I highly recommend reading his blog.

Nevertheless, I find the explanation of central sensitization to be somewhat limiting to achieving better outcomes for my patients.  Don’t get me wrong, it does help, but not an extraordinary game changer.  What I find works better in clinical practice is the term, “Re-sensitization”.  This is an ad-on to central sensitization and of course has to go alongside it in your education, but seems to be more of a heavy hitter in regards to applicability for the individual—especially after he/she has felt results and gained your trust.

In a nutshell, the way I assimilate Re-sensitization to patients is one they understand—it is an exacerbation of symptoms.  We all know this happens for any condition, but especially chronic pain.  I translate the importance of a healthy diet, stress reduction and general exercise, of ways to reduce re-sensitization—-this is a multi system issue (endocrine, metabolic, cardiovascular, etc) and not just musculoskeletal.  But for the main purpose of my point in this post, I recommend  focusing on a specific HEP based off of what worked for the patient under a course of care.

In some individuals, a general exercise program at a gym may just do it.  But what I find, and I’m sure many of you, is that you need something specific for the area/region that seems to be the one that is picked at the most.  It could be a neural glide, self-mobilization, myofascial ischaemic compression, etc etc—-but your job, and what I get most out of the umbrella term of sensitization, is to find and prescribe what works with the upmost confidence and highest power to desensitize the system to prevent re-sensitization.

It works like this: Peripheral sensitization leads to Central sensitization—-we can ramp down this entire system (and local region) through our interventions—-but then Re-sensitization occurs over a course of Time—this is where intervention is needed again—by either specific HEP and or Therapist Treatment.

resensitization

It is challenging to put more concepts into words and make it applicable to your setting, approach, and patient type.  But, I do hope you are learning more about central sensitization and now the phrase re-sensitization—which has been successful for me in the science of pain.  It also helps me establish a wellness program and principle of coming back to me vs medication/physician/surgeon if exacerbation occur as an overall successful business plan.

As an added bonus for reading my blog,, I am offering a FREE, 30 min, E-mentorship session for anyone who feels they would like more information on re-sensitization, but also mentorship and guidance on complicated cases.  Just email me at harrisonvaughanpt@gmail.com with “re-sensitization” in subject line. You may just find it to be beneficial and would like to go through a mentoring process. Feel free to contact me for more information and read about the Program more on my E-mentorship page.

 

 

 

 

Would vascular testing trump + vertebral artery test in this case?

Screen Shot 2015-12-08 at 8.19.26 AM.pngI read with interest this Johnson et al 2008 Manual Therapy by Dr. Johnson on a patient responding to manual therapy after having a (modified) positive vertebral artery test.  This article is not open access but feel free to contact me if you would like it @ harrisonvaughanpt@gmail.com

The Case

The gist is a 24 year old female patient has a 1 year history of dizziness provoked by left cervical rotation and describes it as feeling of anxiety and difficulty communicating.

The clinician’s decision making prompted him to perform the modified vertebral artery test (VAT)—-which was negative to left—-but positive to right for concordant symptoms of dizziness/slow ability to communicate.

Therefore, he referred out for further investigation via duplex ultrasound—which was negative for any significant stenosis in carotids and vertebral arteries.

Considering the negative radiology report—he then proceeded to examine the cervical spine to identify other possible reasons for the symptomology—in this case, finding several tender points bilaterally in the upper trapezius, SCM, levator scapula and anterior scalene muscles.

Only strain-counterstrain techniques were performed—which resulted in a negative finding of modified VAT immediately, after several weeks and again at one year.

Discussion

Overall, I think this is a great case to add to the literature on the limitations (false-positives) of the VAT and I appreciate the authors for taking the time to write it in a respected manual journal.

My big take home from this is :

  • from knowing the limitations behind the VAT,
  • a one year history of symptomology (it wasn’t stated in article why the patient finally sought care from physio—such as an exacerbation, etc)
  • — I wonder if clinical reasoning to refer out for duplex ultrasound due to positive VAT could be trumped by vascular testing (blood pressure, auscultation).

So my question to you is—

If this patient arrived to your clinic with the above symptomology and vascular examination unremarkable, in other words, blood pressure not elevated, negative bruits—-yes, this is a broad statement—

—-would you make the decision to proceed to a manual examination to confirm or refute your hypothesis that the symptomology is arising from a rotational vertebral artery dizziness condition PRIOR to having duplex ultrasound results?

Looking forward to hearing from you!  We can have more discussion in comment section.

Keep learning—Harrison

 

How would you treat this chronic low back pain case? Follow-up

I wrote a post several weeks ago giving readers history and objective findings of a difficult chronic low back pain case.  Revert back to it before reading on.

Patient was treated in physical therapy for 3 weeks with no expression of improvement per SANE scale, no change per GROC, only short term centralization phenomenon but no carry-over beyond 3 hours, and no changes in pain rating scale (still 6/10 currently, 6/10 at best and 6/10 at worse).  However, Oswestry score did decrease from 56% to 42%, a drop from 28 to 21 points, or 7 point difference.

Therefore, even though high construct of central sensitization, “ramped up CNS”…she was referred out as I wasn’t doing anything for her.

She returned to our office s/p 1 week ESI (epidural steroid injection) for further therapy with following results:

1. Her pain is significantly improved and highest pain has been in a week has been 2/10.

2. No leg symptoms (centralized)

3. Only has taken 1 pain pill in a week (initially took pain pills everyday).

Some insight/questions:

1. She did have a positive crossed SLR on initial evaluation (highly specific for IDH)…maybe she did need ESI based on this finding itself…or as my assumption…she was so ramped up that this gave a false positive finding.

2. Even though functionally improved, patient did not express changes at all with a multi-modal physical therapy treatment so don’t rely on functional scales.

3. It has been only a week s/p ESI, but was this the intervention needed for success?

What are your impressions for referring out for ESI? What signs/symptoms indicate success for this procedure, or is it just failure of PT intervention?

This is scientifically accurate, but should it have more jazz?

Photo Courtesy: htt://uthmag.com

Max Zusman has a great Editorial Opinion in the Journal of Multidisciplinary Healthcare in 2013 entitled, “Belief reinforcement. one reason why costs for low back pain have not decreased”.  It is available via open source here.

There are definitely many points out of this piece that could be written about, but I like how he ends the article with a simple narrative of how a clinician could approach a patient prior to performing a manual technique.  It can be rewarding to read opinion pieces in journals as it is the only way to really write how you feel!  Otherwise the writing is more scientific.  Hence a great reason to start a blog.

Here is his exact quote,

Yes, my examination confirms that this particular area of your spine is not moving as it should.  The reason it is prevented from doing so is the presence of pain — that is a part of pain’s job, and we have already discussed the likely chemical basis for you pain.

Because you are unable to move about normally, to get you started I am going to use my hands to help your back move properly.  We are greatly assisted in this regard by the fact that when skillfully applied the treatment I use directly inhibits pain.

Pain inhibition is also useful when your own muscles begin to take over the work.  As things improve you will no longer need it. Nevertheless, I will continue to serve as your active movement guide, and general adviser, for as long as is necessary.

I really can’t disagree with this statement.  It is stated quite neutral, without any obligations to “put bones back in place” or “release muscles”.  It is scientifically accurate.

Although, I wonder if it could be jazzed up a bit more to maximize results?

Recently at the first week of AAMT Fellowship in Orthopedic Manual Therapy, Dr. Justin Dunaway gave an enlightening lecture on the biopsychosocial aspects of pain.  In particular, he spoke about the positive effect of expectation in leverage outcomes.

He quoted the 2008 Bialosky study examining the effect of subject expectation on hypoalgesia associated with SMT.  Even though the all groups demonstrated significant results in pain reduction, the negative expectation group (who would told that SMT is a form of manipulation used to treat low back pain that has unknown effects on perception of heat pain) actually had an increase in pain perception following the procedure.

In addition, he mentioned the Schenk 2013 study.  It concluded that “the deliberate employment of expectancy strengthening strategies in clinical practice offers an important opportunity to increase the therapeutic benefit for the patient”.  For all the brain therapists out there, this was the fMRI study looking at changes at the higher cortical areas.

We can’t leave out the recent Benz/Flynn 2013 study, entitled “Placebo, Nocebo, and Expectations: Leveraging Patient Outcomes”.  This is a must read.

All of us in clinical practice know that some individuals need to have more positive expectations that a treatment would work than others.  These are the ones that you may have to sway for the better, as their mindset is typically ‘glass half-empty’.  They may have already been told by a surgeon that PT is only short-term and will have to go to rehab for 4 weeks prior to receiving an MRI—in order to have surgery to fix the problem.  Whatever the story you may have heard—we all have these patients who need every bit of leveraging to maximize results.

What I am getting to is…maximize the expectation from your procedure.   You don’t have to sell it per say, but express to the patient what you normally see following the intervention.  We know we want a within-visit improvement to get between-visit results for backs and necks. An example:

I am going to perform a manual therapy technique to the area of interest.  I have had very good results with these procedures and based on everything that we have examined and spoke about with your condition so far, you should have excellent results.  Pain relief should be immediate and you should notice an improvement in how you move in the clinic today.

I am not a salesman by trade but my craft is to get people better. Maximizing expectation can be an important ingredient in that craft.

What do you add prior to your interventions?  I think Zusman’s explanation is well done, I just added a bit more expectation language to it. Do you think we should maximize expectations, or minimize the placebo that can go along with it? 

Where and what is your DRIVER?

 

Photo courtesy: aaronshomeinspections.com

The title, “Where and what is your DRIVER”, refers to an area of the body where you think is the pain provocator, source of greatest dysfunction, locator of primary deficits, or in general the most common targeted area to intervene to get the most bang for your buck.  Now that is a run on sentence!

You can also call it the queen bee hive or the sweet spot.  Every therapist has one (or more), I want to hear yours!

This post is more open-ended questions & quick thoughts intended to get your feedback. Let’s start from the head and work our way caudally.

CV: The cranio-vertebral segment can be a prevalent source of dysfunction.  A decreased angle can lead to local neck pain, headaches, dizziness & possible caudal/distal complaints. From having too much upper cervical spine extension compressing the myriad of nerve roots exiting here to motor control deficits of anterior musculature, can this segment be the one?

Photo courtesy: joegambino.wordpress.com

AA: By far a commonplace of pain provocation, the C1-2 segment can be very unpleasant and misbehaves quite often.  It is the most cephalic source of rotation for the body and mostly agreed upon to be source of cervicogenic headaches.  A regular joint for manipulation by chiropractors and top breakout session with accompanying treatment if trained in SFMA.  The obliquus capitis inferior straddles this joint and can be a hot spot for soft tissue treatment by massage therapists, myofascial trained clinicians and dry needlers.

Photo courtesy: pt.ntu.edu

CTJ:  The top two choices above are almost always stemming from hypomobility and derangements at this problematic junction zone.  Can be nicknamed the Pembroke Pines of the spine, this multi-level (C7-T3 segments) is a rigid intersection worth addressing.   Surgeons want to avoid it but we certainly have many approaches to this hostile area.

Photo courtesy: functionalanatomyseminars.com

Scapulae: These girdles work marvelously individually and even together at a mathematically determined ratio with the brachium’s long bone.  Disruption in the firing patterns and postural position can alter how the upper quarter operates and can in turn affect the spine.  We can do so much more than shrug up and retraction down and in to address this area. The Romans thought the bone looked like a trowel, but is this your go-to tool?

Photo courtesy: wikimedia.org

Mid-thoracic spine: The most prominent segment of the spine posteriorly is at T4.  With our ADLs leading more towards a rounded and forward posture, is this level a considerable hazard?  Manual percussion often resonates adversely here and manipulation in this region usually ends with a Kelly Clarkson moment, but in a pain-relieving way.  Manipulation has a powerful effect here, especially due to its close proximity to the autonomic nervous system.

Photo courtesy: core-conditioning.com

Thoracic Ring (ribs): Linda-Joy (LJ) Lee may have hit the center of the universe here.  With the rib’s attachments to the spine posteriorly, the sternum anteriorly and a prime seat next to the diaphragm, the claim of treating this to improve optimal trunk and core function may have some substance behind it.  By encompassing a large percentage of the body, is this the ideal treatment zone?

Photo courtesy: ljlee.ca

Thoraco-lumbar junction:  Not a large threat in my opinion but can be the answer if other locations fail to achieve results.  Flared lower ribs and hyper-lordosis could create mayhem at this sector.

Photo courtesy: spineuniverse.com

SIJ (innominates): You know this could not be left out!  This is by far the site of the most polarizing opinions by clinicians in all fields.  It will be debated and researched until the sun doesn’t shine anymore. Sources show between 10-25% of the LBP arises from the SIJ, but is it 100% in your clinic?  Should we rely on well-documented provocation tests or is there an existence that just can’t be studied by research?

Photo courtesy: kypainmed.com

Hips: Connecting congruently with the innominates through a deep crater and site of concentric action anteriorly during the first steps of the gait cycle, how can it not get into trouble?  Weakness in the lateral/posterior structures has been demonstrated every month in JOSPT for the last 5 years to be related to just about every condition and controversy continues to exist for tightness in the IT Band and hip flexors.  Is there truth to all this madness?

Photo courtesy: thesportsphysiotherapist.com

Foot/Ankle Complex (FAC):  As soon as the feet hit the floor, dysfunction in the mingled array of bones and tendons that attach to almost every bone has to create dilemmas right?  Are we relying too much on orthotics, inserts and cushion shoes with our modern advances? Is this area becoming a light-weight that can’t handle forces anymore?  Is treating it just a gimmic or is there substantial certainty that this complex is the one?

Photo courtesy: workingperson.me

So where is your bread and butter intervention that gets maximal results?  Did your work-horse territory make the list above?  I didn’t include much soft tissue areas, what do the myofascial therapists think? Where IS  the underlying problem area? Or, IS THERE ONE? Is is like trying to find a needle in a haystack? Let’s hear (read) your feedback in discussion below.

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