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

 

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

 

45 years later, reality may finally set in

Any manual therapists in the physical therapy / physiotherapy world should know the influence of Dr. James Cyriax.  Essentially, he can be the reason that our profession has the ability to perform manual therapy, especially manipulation.  He has been quoted to say, “physiotherapists were the most apt professionals to learn manipulative techniques”.  Some may say that he was light years ahead in current thinking in regards to care for musculoskeletal conditions, especially in regards to clinical reasoning biomechanics, anatomy and physiology.

I recently read one of Cyriax’s column, entitled Manipulation by Physiotherapists in The Australian Journal of Physiotherapy in 1970.  Yes, 1970…45 years ago last Sunday!  You may find the cropped sentence below interesting.

cyriax

 

I’ll highlight the sentence worth mentioning, …“the successful candidates were placed on an official register of manipulating physiotherapists to which doctors refer when seeking such treatment”

The summary of the column is exactly what is in the title: Manipulation by Physiotherapists.  Cyriax makes the argument that we can the best advocate of this intervention and if we do not perform it, then patients would seek out other practitioners (in this article, bone setters, hence its age) to have manipulation.

The bottom line is, why not have specialized physiotherapists who have been successfully trained and have the foundation knowledge in the sciences, as well as connection with the medical field?  If appropriate, these specialists can be referred to specifically by medical physicians or sought out personally by consumers?  Cyriax had this dream 45 years ago, now is it a reality?

If you want the following article, email me and I’ll send you a copy. 

Cyriax J (1970): Manipulation by physiotherapists. Australian Journal of Physiotherapy 16: 32-36.

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?

What is the tissue source in low back pain? Part 2

I polled my readers several weeks ago asking them what they thought the tissue source was in low back pain?  Thanks to everyone who responded and provided feedback!  Results are:

tissue source in low back pain
tissue source in low back pain

An overwhelming winner at 41% “none: pain does not equal tissue damage”

So my next thought is: with this rationale, how would you treat an individual coming into your office?  I know this is a loaded question which varies from patient to patient, but everyone has their “go-to” treatment.  What is your typical “talk” that leads to an active recovery?

 

How would you treat this chronic low back pain case?

Subjective History: 35 y/o female presents with hip and back pain.  She had no injury or accident but has been dealing with back pain for 5-6 years.  She sought care from surgeon who ordered MRI (5-6 yrs ago) that showed DDD but that she was too young for surgery and has to deal with the pain.  In Feb 2014, her right hip “gave out” on you on her way to work one morning.  The sensation was a pinching in the groin that hurt on every step.  It hurt so bad that she went to ER who then referred her to Dr. *&$^(.  She has had multiple x-rays, bone scan and then MRI of hip showing a torn labrum in April 2014.  She wound up losing her job after 14 yrs due to not being released to go to work.  She had another consult in Sept 2014 with a surgeon for hip, but was told to lose weight and she was not a candidate for surgery.  She started another job (that involved 8 hrs of standing) shortly thereafter but after one week, she could hardly stand due to right hip pain arising again and numbness in right leg.  She then sought care from her PCP, Dr. *^%*, who referred her for CT scan (for back) and then to Dr. *$&^.  She had a consultation and then referred to PT.  She was told she would have injections.

Onset

Date of Onset: Back pain and numbness in right leg for past 5-6 years. Right hip pain started Feb 2014. In 2010, she had to have ambulance get her from her house due to her back giving out and right leg “stuck” resulting in her having to be put asleep to get the right leg extended again. Onset Due To: Unknown. Recent Symptom Trend: Condition worsening.
Symptoms
Primary Symptoms: She c/o numbness down right leg from hip posteriorly to 5th digit. Provokes symptoms: Any movements. Hurts with standing/walking/sitting and doesn’t matter what type of chair. Relieves symptoms: trying to stretch (nothing specifically) and sometimes medication.

Pain Rating:

Currently: 6.5/10, Best: 3.5/10 (between stretching and medication), Worse: 10/10 (see above but also occurs weekly).

Sleep Disturbance: She barely sleeps. She tosses and turns all night only getting 4-5 hours. This has been going on for years.

Vocational
Current Status: Not working. Has lost 2 jobs in last few years due to functional limitations.

Objective
FABQ (work): 19, FABQ (physical activity): 22.

Oswestry: 56%

Observation: Unable to stand without dysfunctional pattern and using B UE for support.

Observation: Single leg stance 5″ on left limb, 1″ on right limb.

Palpation

Hypersensitivity along entire lumbar spine from L1-S4 mostly centrally > laterally ~3 fingerbreadths from SP

Lumbar Spine Flexion: 
Very restricted to patella bil and pain low back (all AROM equally painful in same location in LB)
Lumbar Extension:
Very restricted
Only ~5 degrees. (all AROM equally painful in same location in LB)
Lumbar L Side Bending: 
Very restricted
Only ~10 degrees. (all AROM equally painful in same location in LB)
Lumbar R Side Bending:
Very restricted
Only ~10 degrees ((all AROM equally painful in same location in LB))

Reflex Tests
Achilles Tendon Reflex (S1)
Absent (0) on right, 1+ on Left
Patellar Tendon Reflex (L4)
Diminished (1+) bilaterally

Neurodynamic Tests
SLR
Positive
~40 deg SLR for LB but not leg symptoms on LEFT, and ~20 deg SLR for LB but not leg symptoms on RIGHT (+ crossover)

Lower Extremity Dermatomes (to sharp prick):
L1: Inguinal Region: Intact

L2: Upper Thigh: Intact

L3: Mid Thigh: Intact

L4: Patella, medial leg, medial malleolus: Intact

L5: Dorsum of foot, 3rd metatarsophalangeal joint: Intact

S1: Lateral aspect of calcaneus, lateral aspect of posterior leg: Diminished
Absent to lateral aspect of foot from calcaneus to MCP of 5th digit.

S2:Medial aspect of posterior leg: Intact

Lower Extremity Myotome Strength

L2: hip flexion: 4/5
Generally weaker on right side
L3:Knee extension: 4/5
Generally weaker on right side
L4: Ankle Dorsiflexion: 4/5
Generally weaker on right side
L5: Great Toe Extension: 4/5
Generally weaker on right side
S1: Ankle Plantarflexion: 3-/5
Unable to perform single calf raise on RIGHT, 18 reps on LEFT
S2: Knee Flexion: 4/5
Generally weaker on right side

With the information provided, how would you proceed? What other objective/subjective information do you need?  Is this individual appropriate for PT services?

Differential Diagnosis — Low back & lower extremity case: Part 1

Looking for feedback on this case.  Questions will be provided at end of blog post below case.

Script: Lumbar Disc Herniation.

Medical History: (I am listing the “Yes” remarks from intake form):

-Positive for arthritis

-Positive for sleeping difficulties

– She smokes 1/2 pack a day and 4 packs a week

– She doesn’t work out but does enjoy walking sometimes

Subjective History: 32 yo female presents with main complaint of back pain and BIL LE. It all started with Bil LE pain but she has had a history of low back pain which was just uncomfortable, but now it is unbearable.  This arose during the month of August following a surgical procedure following a miscarriage (patient was unsure of procedure but I am assuming D&C).  She consulted with her surgeon but he is unsure why she is having symptoms following this procedure.  She was then referred to a spine surgeon who referred to PT for 4 visits until he can order an MRI.

Prior history: She has had one other miscarriage in the past.  She says she is not sure why she miscarriaged then and even now.  Her MD doesn’t know either.  She is not sure if her mother had miscarriages either.  She has one son who is 6 years old.

Date of Onset: Mid-August 2014 (4 months ago). Onset Due To: Arose after D&C.

Recent symptom trend: Since August, the pain has spread from the thighs to the low back. Pain is mostly in the thighs, but will work to the calves at times, but cannot provide any further information of why.

Pain Rating
Verbal Pain Rating at Present: 8 /10
Verbal Pain Rating at Best: 6/10 (Over the past week)
Verbal Pain Rating at Worst: 10 /10 (Over the past week)

Quality of symptoms:  She describes the back pain as unbearable at times.  But for the most part, everything is just “sore”.  She has trouble moving around.  She feels like everything needs to pop. Her symptoms are mostly in the thighs, equally bilaterally, and circumferentially.  She says this is numbness/tingling and burning.  She also describes muscle spasms in the same location that is painful.

Provokes symptoms: Any movements could do it, but also she can have muscle spasms that arise just sitting.  She denies any postures, movements or positions that make symptoms better or worse.   Relieves symptoms: Lying down with heating pad (legs elevated).  Medication as prescribed.

Medication: Prescribed muscle relaxer (Skelaxin) that she takes 1-2x/day as needed.  Was prescribed a 10 day prednisone series

Sleep: She only gets half the amount of sleep than she did prior to procedure.  She says she wakes up several times a night and it can keep her awake for several hours at at time.  She just lies there and watches TV.

Further questioning:  PT in italics, patient in normal font.

Are you having any changes in your bowel or bladder? No.

Are you having any painful urination or bowel movements? No.

Are you having any pain with intercourse? No.

Any discoloration in your urine or bowels? No.

Are you having any abdominal pain? Yes but only came on after taking Diclofenac as prescribed by MD.  However, I am not taking this medication anymore due to the effects.

Where was it hurting in your abdomen? Generally in lower abdomen pointing diffusely in this region.

Do you notice the lower limb symptoms at different times of the day? Yes, it gets worse as day progresses but blames it on just being active to do daily tasks.

 

What are your top 3 diagnoses so far?

What other questions would you ask prior to proceeding to objective exam?

Is this what our profession continues to do with LBP?

I was recently evaluating a patient for low back pain who within the last 6 months had PT at another location for same condition. I asked him what type of procedures were performed to assist in his recovery.  I tend to do this in general to get an idea of what works and what doesn’t work so I am not performing same treatment hoping for a different result (as it didn’t work for pain relief or function at previous clinic).

I noted what he said in bullet form verbatim:

  • “Get on bike and pedal”
  • “pull rubber bands”
  • “band pull machine”
  • “leg presses with total gym”
  • “knees to chest lying on back”
  • “rolling ball on one side of table to the other”
  • “massages”
  • “put heat and electrical on back”

If this patient was telling a friend, family member or even healthcare professional…what would they THINK we do as a physical therapy profession?

I can tell you: A bunch of rolling around exercises with a ball and massages to the low back with heat.

Get real guys.  Patients need and want more than this.

As much as some people will bash mobilizations/manipulations/dry needling or that we do not need specific directional exercise training, these procedures carry weight in what patients remember and pass on to others about what we DO as a profession.  Specialization is in our future as patients will need to seek it out.

Results carry weight too.  My experience and anyone else who treats back pain in the clinic everyday will tell you that the rubber bandy pulls do not get results.  Lack of results do not progress our profession.  Patients continue to seek services elsewhere.

Finally, research has caught up with clinical practice

I am sure all of you have heard the phrase that clinical practice is ~13-18 yrs  behind what research shows is effective.  Meaning, it takes this amount of time for changes to occur clinically based on sound evidence.  This may shorten with the access to relevant research (blogs, Twitter, Pedro, etc.), but to be realistic, it probably will not.  This is like kicking a dead horse, but hasn’t ultrasound been proven to be ineffective but still in use in clinics?

On the flip side, as I am hustling out here in clinical practice, I know there is a lot of what we do that has not been documented in the research.  I think everyone who practices will agree.  Where would we be if we just relied on relevant research?

In the recent JOSPT, Dr. Salvatori and company presented a case report entitled, “Use of Thoracic Spine Manipulation on Neck Pain and Headache in a Patient Following Multiple-Level Anterior Cervical Discectomy and Fusion: A Case Report“.

The following is a quote from the introduction section (emphasizing bold),

A high percentage of patients may experience neck pain 1 year following ACDF surgical intervention.53 Previous studies evaluating the effectiveness of thoracic spine thrust manipulation have not included individuals post-ACDF, primarily due to study exclusion criteria.16,19,20,35,36,43,65 Consequently, utilization of this manual therapy technique may not be considered as routine physical therapy care, based on either postoperative protocols or lack of empirical studies to support its clinical effectiveness in this specific patient population. Therefore, the purpose of this case report was to describe the physical therapy management, which included thoracic spine thrust manipulation, and outcomes in a patient referred to physical therapy with neck pain and headache following an ACDF surgical procedure.

I am very surprised that there is no research on the use of thoracic manipulation for this subgroup of patients.  Haven’t we all performed a technique similar to this with great outcomes following ACDF?  Now granted this is low level evidence (I do like case reports), but this is what we really need in the literature.  I applaud the authors for putting this case together.  Finally, research has caught up with clinical practice.

 

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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