Cervicogenic Dizziness
Differential Diagnosis & Treatment
Jessica Pyatt, SPT
Regis University
July 2010
Case Presentation
Objectives
• By the completion of this case presentation the
audience will:
▫ Be able to indicate potential patient presentation/
history items in individuals with cervical spine
associated dizziness
▫ Be able to transfer evaluative T&M to the differential
diagnosis of individual’s with / without cervicogenic
dizziness.
▫ Ascertain potential treatment options for patients
with cervicogenic dizziness
Why Should I Care?
• 8 Million primary care visits for dizziness / year
• Individuals over 65 y/o:
▫ 39% of falls partial attributable to dizziness
• Whiplash Associated Disorder
▫ Resulting Dizziness in:
▫ 40-80%
▫ 20-58%
• 1/3 of individuals with neck pain also have dizziness
▫ Prolonged disability / pain
Humphreys 2008; Reid 3005
Patient Presentation
• Female, 62 y/o
• L > R scapular / upper trap and neck pain
• Headaches & Dizziness:
▫ along temples, behind eyes with nausea and dizziness
▫ “head does not belong to my body” “disorientated/off”
• Light headedness:
▫ stands too fast / up at night
• Falls 2-3 x / week
• Worse:
▫ with/at work, stress, computer use, rotating head & neck
• Better:
▫ pain medication, self message, up and moving around
(walking/not at computer)
Medical History
• Breast cancer:
▫ L mastectomy, Tran Flap reconstruction, R
lumpectomy & radiation
• Osteoporosis
• Scoliosis
• Arthritis: neck, low back,
▫ Jt pain & swelling
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HTN ∞
Stomach / GI / IBS
Depression ∞, anxiety ∞ (including sleeping medication)
Difficult concentrating, fatigue & stress
Patient report of unremarkable imaging *****
∞ Medications
Observation
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Guarded
Slight forward head posture
“cranial shift’’/ upper cervical SB
Nodding of head / neck to look over glasses
L shoulder elevation
Flat thoracic spine
Thoracic: R convexity scolosis
Palpation:
▫ Thoracic right prominence throughout / R rotated,
▫ B upper trap / scapular/ RTC tenderness / spasm
▫ B 1st rib tenderness
Screening Exam
• BP 124/78
• Strength: WNL
• Sensation:
▫ WNL to light touch bilaterally
• Reflexes: 2+ symmetrical
• Hoffman’s: negative
• Cervical ROM:
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Flexion: 56 (WNL)
Extension 75 (WNL) ∞ “tight”
Sidebend: L = 57 R = 46 ∞ “tight”
Rotation: L = 68 R = 55 limited, slight provocation
Differential ??????
Differential
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Wrisley, 2000; Landel 2010; Brandt, 2001
BPPV
Perilymphatic fistual
Labyrinthine concussion
Migraine –related vertigo, photophobia
Central / peripheral vestibular dysfunction
VBI – vetebral basilar insufficiency
Vestibular system / vestibular nerve
Brain injury / central vestibular
Orthostatic Hypotension / vascular
Double vision – glasses
Oculomotor
Drugs / alcohol intoxication
“Diagnosis of Exclusion”
• Rule Out Red Flags:
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Oculomotor tests
Nystagmus-???
Smooth pursuit - ????
Vetebral Artery
• Peripheral :
▫ Position
▫ Hallpike
▫ ENG/VNG
• Orthostatic Hypotension
Cervicogenic Dizziness Description
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Vague
Not spinning / vertigo like
Unsteady
Spacey
Disconnected
Disoriented
Floating
Lightheaded – without faint feeling
Difficult concentrating
Special Tests
• Sharp Pursuer: Negative
• Alar Ligamant testing (SB & rotation): negative
• Transverse Ligament Test:
▫ Negative ???
▫ Prolonged hold 30 seconds = slight nausea
 On a bad day / retesting
• OA nodding / AA rotation
▫ Symmetrical
▫ AA slight limitation
Special Tests
• Sustained End Range Rotation: Negative bilaterally
▫ No change in blood flow at C1/2, C5/6 during hold
▫ Reduction on return to neutral
▫ Rest period for pre-manipulative /
manual testing Zaina 2003
• Spurlings:
▫ Bilaterally reproduced upper cervical pain, no UE s/s
• Compression:
▫ reproduces L sided neck pain
• CRLF: + Right
Cervical vs Vestibular
Move body under head:
Head and neck together as one unit:
+ symptoms suggests cervical + symptoms central or peripheral
vestibular involvement
involvement
+ with body turn L / R cervical
rotation
Sensory Systems
Visual
Vestibular
Somatosensory
C1-C3
Mechanoreceptors
Cervical Dorsal
Roots
Vestibular Nuclei
Superior
Colliculus
Coordinate visual
& cervical motion
Sensory
Cervicogenic
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Vague dizziness description
Episodes with neck movement
Imbalance
Occipital/ bi-temporal headaches
Episodic dizziness minutes to hours *****
“head not straight”
Not walking straight
Falls
Impaired ROM
Oculomotor abnormalities
Cervicogenic Dizziness
• Dizziness & Neck Pain Together
• Postural control / increased sway
• Cervical muscle function
▫ DNF
▫ Extensors
• Joint position errors
• Temperature hypersensitivity
• Post-traumatic stress
Neck Pain
Manual PT of Cervicogenic Dizziness: A Systematic Review
(Reid 2005)
Low quality – Level 3 Evidence
Positive / Significant improvement with manual PT
Wrisley, 2000: 73-82% of patients
reduced s/s with manual PT
Karlberg, 1996
Malmstrom 2007
Treatments:
Jt mobilization
Soft Tissue
Stabilization
Relaxation
Ergonomic
Self “SNAG”
Reid, 2008
Postural Control
• Balance Training
Posture & Ergonomics
Cervical Flexion Test
• Staged test of deep cervical flexor motor control
• Air filled stabilizer sensor
• Start: 20 mmHg, 2 mmHg increments
▫ Hold 5 or 10 seconds
▫ No SCM contraction / no head lift
• Results: 26 mmHg x 10 sec
Jull, 2000; Falla 2003, 2004
• WAD average 23+/- 1.3 mm,
• Asymptomatic average 28 +/- 1.7 mmHg
Deep neck flexor endurance: 23 seconds
Cervical Extensors
Joint Position Error
• 90 cm from wall
• Eyes closed
• Angle = tan-1 (error distance / 90 cm)
▫ 7.1 cm = 4.5 degrees
▫ Greater than 4.5 degrees = impairment
• Lee, 2006 test, retest reliability of assessing jt position error
• Kristjansson 2009 Expert Opinion / Clinical Review
• Lee, 2006: Test-retest reliability of cervicocephalic kinestathic
sensibility
• Jull 2007: Reduction in jt position error with training
• Revel, 1994
Outcomes…....Still to Come
• Dizziness VAS: 6/10 average at intake
• NDI :
▫ 6-2-10: 14/50 or 28%
▫ 6-16-10: 24/50 or 48%
6-16
• FABQPA: 12/24
• FABQW: 20/42
• Pain VAS: 6-7/10 ---- 2/10 ---- 3-4/10
• Decreased frequency of dizziness sxs / week
Du, du, du, du…du, du, duuuu.
Du, du, du, du DU, dudududuuu.
• Name one sxs that must accompany ‘dizziness’ to
be cervicogenic in origin……
• Cervicogenic dizziness is described as………..
• Normal deep neck flexor endurance is ______.
• Normal cervical joint position error is less
than ________ degrees.
Psychosocial Aspects
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Emotional
Disorientation
Depression
Anxiety
Fear of open spaces
Inability to perform ADLs
Employment (Gudleski, 2005)
7-14 Days
Stress
Episodes
IBS /
Pain /
Dizziness
References
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Alix ME, Bates DK. A proposed etiology of cervicogenic headache: the neurophysiologica basis and
anatomic relationship between the dura mater and the rectus capitis minor muscle. J Manipulative Physio
Ther. 1999; 22: 534-539.
Brandt T, Bronstein AM. Cervical vertigo. J Neurol Neurosurg Psychiatry. 2001. 71: 8-12.
Eldridge L, Russel J. Effectiveness of cervical spine manipulation and prescribed exercise in reduction of
cervicogenic headache pain and frequency: a single case study experiemental design. Int J Osteo Med. 2005;
8: 106-113.
Landel R. Cervicogenic dizziness: perspectives on evaluation and treatment. American Physical Therapy
Association. Combined Sections Meeting. San Diego, CA. 2010
Falla DL, Jull GA, Hodges PW. Patients with neck pain demonstrate reduced electromyographic activity of
the deep cervical flexor muscles during performance of the craniocervical flexion test. Spine. 2004; 29:
2108-2114.
Falla DL, Campbell CD, Fagan AE, Thompson DC, Jull GA. Relationship between cranio-cervical flexion
range of motion and pressure change during the cranio-cervicla flexion test. Manual Ther. 2003; 8: 92-96.
Gudleski GD. Major disasters, stress and GI symptos: the September 11th tragedy and its effect on persons
with irritable bowel syndrome. State University of New York at Buffalo Thesis. 2005. DAI-B 66/08, p. 4482.
Huijbregts P. Vidal P. Dizziness in oprthopaedic physical therapy practice: classification and pathophysiology.
J Man Manip Ther. 2004; 12: 199-214.
Jull GA. Deep vertical flexor muscle dysfunction in whiplash. J Musculo Pain. 2000; 8: 143-154.
Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B. Retraining cervical joint position sense: the effect of two
exercise regimes. J Ortho Resear. 2007; 25: 404-412.
References
• Karlberg M, Magnusson M, Malmstrom EM, Melander A, Moritz U.Postural and symptomatic
improvement after physiotherapy in patients with dizziness of suspected cervical origin. Arch Phys
Med Rehbil. 1996; 77: 874-882.
• Kristjansson E. Treleaven J. Sensorimotor function and dizziness in neck pain: implications for
assessment and management. J Orthop Sports Phys Ther. 2009; 39: 364-377.
• Lee HY, Teng CC, Chai HM, Wang SF. Test-retest reliability of cervicocephalic kinesthetic sensibility
in three cardinal planes. Manual Ther. 2006; 11: 61-68.
• Malmstrom EM, Karlberg M, Melander A, Magnusson M, Moritz U. Cervicogenic dizziness –
musculoskeletal findings before and after treatment and long-term outcome. Disabil Rehabil. 2007;
29: 1193-1205.
• Ogince M, Hall T, Robinson K, Blackmore AM. The diagnostic validity of the cervical flexionrotation test in C1/2-related cervicogenic headache. Manual Ther. 2007; 12: 256-262.
• Reid S, Rivett DA, Katekar MG, Callister R. Sustain natural apophyseal glides (SNAGs) are an
effective treatment for cervicogenic dizziness. Manual Ther. 2008; 13: 357-366.
• Reid SA, Rivett DA. Manual therapy treatment of cervicogenic dizziness: a systematic review.
Manual Ther. 2005; 10: 4-13.
• Revel M, Minguet M, Gergory P, et al. 1994. Changes in cervicocephalic kinesthesia after a
proprioceptive rehabilitation program in patients with neck pain: a randomized controlled study. Arch
Phys Med Rehab 75: 895–899
• Strunk RG, Hawk C. Effects of chiropractic care on dizziness, neck pain, and balance: a single-group,
preexperimental, feasibility study. J Chiro Med. 2009; 8: 156-164.
• Zaina C, Grant R, Johnson C, Dansie B, Taylor J, Spyropolous P. The effect of cervical rotation on
blood flow in the contralateral vertebral artery. Manual Ther. 2003; 8: 103-109.
Questions???