Cervicogenic Dizziness Differential Diagnosis & Treatment

Jessica Pyatt, SPTRegis University July 2010Case 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 •HTN ∞•Stomach / GI / IBS•Depression ∞, anxiety ∞ (including sleeping medication)

•Difficult concentrating, fatigue & stress •Patient report of unremarkable imaging *****

∞ Medications

Observation•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:

▫Flexion: 56 (WNL)▫Extension 75 (WNL) ∞ “tight”▫Sidebend: L = 57 R = 46 ∞ “tight” ▫Rotation: L = 68 R = 55 limited, slight

provocation

Differential ??????

Differential •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

Wrisley, 2000; Landel 2010; Brandt, 2001

“Diagnosis of Exclusion”•Rule Out Red Flags:

▫Oculomotor tests▫Nystagmus-???▫Smooth pursuit - ????▫Vetebral Artery

•Peripheral : ▫Position▫Hallpike▫ENG/VNG

•Orthostatic Hypotension

Cervicogenic Dizziness Description •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: + symptoms suggests cervical

involvement+ with body turn L / R cervical

rotation

Head and neck together as one unit: + symptoms central or

peripheral vestibular involvement

Sensory Systems

Visual

SomatosensoryVestibular

Sensory

C1-C3 Mechanorecepto

rs

Cervical Dorsal Roots

Vestibular Nuclei

Superior Colliculus

Coordinate visual & cervical

motion

Cervicogenic •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

Treatments:Jt mobilization

Soft TissueStabilizationRelaxationErgonomic

Neck Pain

Manual PT of Cervicogenic Dizziness: A Systematic Review (Reid 2005)

Low quality – Level 3 EvidencePositive / Significant improvement with manual PT

Wrisley, 2000: 73-82% of patients reduced s/s with manual PT

Karlberg, 1996Malmstrom 2007

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•Emotional•Disorientation•Depression•Anxiety•Fear of open spaces•Inability to perform ADLs•Employment (Gudleski, 2005)

Stress Episodes

IBS / Pain /

Dizziness

7-14 Days

References • 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 11 th 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 flexion-rotation 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???