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Journal of Orthopaedic Sports Physical Therapy
2000;30 12) 755-766
Cervicogenic Dizziness Review of
Diagnosis and Treatment
Diane M. Wrisley MS P7; NCS1
htrick J Sparto Ph D PT2
Susan I Whitney PhD P7; ATC3
Joseph M. Furman MD PhD2
The diagnosis of cervicogenic dizziness is characterized by dizziness and dysequilibrium
that is associated with neck pain in patients with cervical pathology. The diagnosis and
treatment of an indiv idual presenting with cervical spine dysfunction and associated
dizziness complaints can be a challenging experience to orthopaedic and vestibular
rehabilita tion specialists. The purpose of this artic le is to review the incidence and
prevalence historical background and proposed pathophysiology underlying cervicogenic
dizziness. In addition we have outlined the diagnostic criteria evaluation and treatment of
dizziness attributed to disorders of the cervical spine. The diagnosis of cervicogenic
dizziness
is
dependent upon correlating symptoms of imbalance and dizziness with neck
pain and excluding other vestibular disorders based on history examination and vestibular
function tests. When diagnosed correctly cervicogenic dizziness can be successfully treated
using a combination of manual therapy and vestibular rehabilitat ion. We present cases of
patients diagnosed with cervicogenic dizziness as an il lustration of the cl inica l decision-
making process in regard to this diagnosis. Orthop Sports Phys Ther
2000;30:755 766.
Key
Words
cervical vertigo dysequilibrium whiplash
he diagnosis and treatment of an individual presenting
with cervical spine dysfunction and associated complaints
of dizziness can be a challenging experience to orthopaed-
ic and vestibular rehabilitation specialists. The differential
diagnosis may include cervicogenic dizziness, benign parox-
ysmal positional vertigo, perilyrnphatic fistula, labyrinthine concussion,
migraine-related vertigo, and central or peripheral vestibular dysfunc-
tion. Th e decision to treat the patient o r refer to another healthcare
professional is essential to providing appropriate and timely care. Given
the potential seriousness of some of the causes of dizziness, physical
Department of Physical Therapy School of Health and Rehabilitation Sciences University of Pitts-
burgh Pittsburgh Pd
Department of Otolaryngology School of Medicine Department of Physical Therapy School of
Health and Rehabilitation Sciences University of Pittsburgh Pittsburgh Pd
Department of Otolaryngology School of Medicine Department of Physical Therapy School of
Health and Rehabilitation Sciences University of Pittsburgh Pittsburgh Pd; Center for Rehab Ser-
vices Vestibular Rehabilitation Center Pittsburgh
Pd
Send correspondence to: Pdtrick 1 Sparto University of Pittsburgh Department of Physical Therapy
6035 Forbes Tower Pittsburgh PA 15260. E-mail: [email protected]
therapists must learn how to elicit
a thorough history that will pro-
vide the information necessary to
make decisions about treating the
patient or referring the patient to
another health care practitioner.
We borrow the definition of cer-
vicogenic dizziness from Furman
and Cassw: a nonspecific sensa-
tion of altered orientation in
space and dysequilibrium originat-
ing from abnormal afferent activi-
y from the neck. Cervicogenic
dizziness does no t result from ves-
tibular dysfunction and, therefore,
rarely results in true vertigo.'O Cer-
vicogenic dizziness is most often
associated with flexion-extension
injuries and has been reported in
patients with severe cervical arthri-
tis, herniated cervical disks, and
head tra~m a. J. ~n these pa-
tients, complaints of ataxia, un-
steadiness of gait, or postural im-
balance associated with neck pain,
limited neck range of motion, or
headache pr ed ~m ina te . '~ . ~his
article will focus on the incidence
and prevalence, historical back-
ground, and proposed pathophysi-
ology underlying cervicogenic diz-
ziness. In addition, we will address
the diagnostic criteria, evaluation,
and treatment of dizziness attrib-
uted to disorders of the cervical
spine. When diagnosed and treat-
ed properly, the symptoms of cer-
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vicogenic dizziness can
be
reduced, resulting in im-
HISTORICAL BASIS AND PATHOPHYSIOLOGY OF
proved function. CERVICOGENIC DIZZINESS
INCIDENCE AND PREVALENCE
The concurrence of dizziness complaints and cer-
vical spine dysfunction is commonly associated with
flexionextension injuries (whiplash) acquired in a
motor vehicle accident. It is estimated that every year
0.1% of the population experiences a whiplash inju-
~-y.~-@'ignificant disability can result, with an estimat-
ed 20% of individuals who experience whiplash re-
quiring greater than 20 weeks to return to work.@'
Furthermore, a significant proportion of those who
experience whiplash complain of neck pain months
after the injury occurred?
The primary symptom of whiplash is neck pain,
which is reported by 62-100% of study participants
in initial evaluations after the hipl lash ^^^^^^^^^^^^^ The
next most common symptom is headache (primarily
occipital in location), which occurs in 6M 7 of the
study
population^ ^^ ^^ ^^^
Although dizziness, vertigo,
and dysequilibrium d o not frequently occur at the
initial presentation to the emergency department, .57
20-58% of individuals who have sustained a closed
head or whiplash injury will experience these symp
toms.58.64.71
Vestibular system disorders are included in the dif-
ferential diagnosis of patients with dizziness associat-
ed with cervical spine dysfunction. For example, diz-
ziness following neck injury may be du e to vestibular
system pathologies, brain injury, or cervicogenic diz-
z i n e s ~ . ~ ' . ~ . ~everal groups have examined the occur-
rence of vestibular disorders following wh ip
lash.21.24.4n..-.71 Table 1 provides operational defini-
tions for frequently used terms regarding vestibular
pathology that may be unfamiliar to the reader. Rou-
tine tests that are performed for the diagnosis of ves-
tibular disorders are described in Table 2. Abnormal-
ities have included deficits in smooth eye pursuit,
normal or hypoactive caloric vestibular responses,
spontaneous and positional nystagmus, and impaired
postural ~ o n t r o l . ~ ~ ~ ~ . ~ ~ - ~ ~
Reports of dizziness with other types of neck dys-
function are certainly not as prevalent as with whi p
lash. However, several case reports have demonstrat-
ed dizziness in patients with cervical spine spondylos-
is and cervical muscle spasms. Ryan and CopeGS e-
ported
3
cases of dizziness that they attributed to
cervical spondylosis. The symptoms of 3 patients with
dizziness and painful posterior cervical muscles re-
duced with an injection of anesthetic into the poste-
rior neck m ~ s c l e s . ~ ~ . ~ervicogenic dizziness may be
a result of whiplash injury, other forms of cervical
spine dysfunction, o r spasms in the cervical muscles.
Brown2 relates that the contribution of the cervi-
cal region to balance has been studied experimental-
ly in animals for 150 years. Strong connections have
been demonstrated between the cervical dorsal roots
and the vestibular nuclei with the neck receptors
(such as proprioceptors and joint receptors) playing
a role in eye-hand coordination, perception of bal-
ance, and postural adjustments. Brownz0 provides a
comprehensive review of this literature. With strong
connections between the cervical receptors and bal-
ance function, it is understandable that injury or pa-
thology of the neck may be associated with a sense of
dizziness or dy seq uil ibr i~ m.~
Dizziness that is presumed to occur due to dys-
function in the cervical spine has been recognized
since early in the 20th century. Symptoms of cervico-
genic dizziness were thought to be due to abnormal
input from cervical sympathetic nerves based on the
work of Barrelo and Lieow% in the 1920's. They ex-
perimentally induced dizziness, tinnitus, and Hor-
ner's syndrome (constriction of the pupil, ptosis, ipsi-
lateral loss of sweating) by injecting anesthetic into
the upper cervical region. No sympathetic or vascular
changes were subsequently identified that could ac-
count for these symptoms and this theory lost favor.m
In the 1950's, there was a resurgence of interest in
the idea that dizziness may be related to pathologies
of the cervical r e g i ~ n . ~yan and Cope introduced
the term cervical vertigo and although vertigo as
defined in Table 1 is rarely a symptom, cervical verti-
go has remained the most popular name for the fo-
cus of Ryan and Cope's paper. These authors theo-
rized that cervicogenic dizziness was due to abnor-
mal afferent input to the vestibular nucleus from
damaged joint receptors in the upper cervical re-
gion. They described
3
types of patients that display
this syndrome: patients with cervical spondylosis, pa-
tients treated with cervical traction, and patients fol-
lowing neck trauma. Graf4 found that he could re-
lieve dizziness considered to be related to cervical
muscle dysfunction by injecting anesthetic into the
posterior cervical muscles. This finding supported
Ryan and Cope's- theory that abnormal afferents
from the cervical region caused dizziness and dyse-
quilibrium.
Others have experimentally produced a revers-
ible lesion in the cervical region and observed defi-
cits in balance and vision. CohenZJdescribed deficits
in balance, orientation, and coordination in primates
following injection of anesthetic in the upper 3 cervi-
cal dorsal roots. Biemond and de Jong15 reported
that injection of anesthetic into the neck of rabbits
induced positional nystagmus. Later, de Jong and
colleaguesw found that injection of anesthetic
around the dorsal roots of rabbits, cats, and primates
756
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TABLE 1 Definition of terms.
Term Definition
Ataxia
Dizziness
Dysequilibrium
Saccades
Visual smooth pursuit
Unsteadiness of gait
Vertigo
Labyrinth ine concussion
Mi ld brain injury
Benign Paroxysmal Positional Vertigo (BPW)
Perilymphatic fistula
Whiplash
The inability to produce smooth, coordinated movements.12
A nonspecific term that describes an altered orientation in space. It may include
sensations of light-headedness, heavy-headedness, faintness, giddiness, un-
steadiness, imbalance, falling, waving, or f l~a t ing .~
The inability to maintain upright po st ~r e. ~
A rapid change in eye position, usually to shift gaze quickly from one object to
an~ther.~ ' .~ '
The ability to maintain gaze on a moving object.75
Abnormal sway or gait pattern during amb~lation.~~
An illusory sensation of motion (rotational, translational, or tilting of the visual
environment) of either self or sur ro~ndings.'~
A peripheral vestibular impairment caused by head trauma that usually is mani-
fested by unilatera l hearing loss and unilatera l reduced peripheral vestibular
function. Patients wil l typically complain of fluctuating vertigo and dysequili-
brium.38
Injury to the brain characterized by brief loss of consciousness or coma less
than 1 hour.
A disorder caused by the presence of debris in the semicircular canal. Patients
will typically complain of short episodes of vertigo when rolling over in bed,
reaching up, or bending over. The D ix-Hallp ike Maneuver is used to diagnose
BPW. If present, the patient will present with nystagmus that begins
5-15 sec-
onds after the patient is positioned and lasts for 30 seconds to 1 minute.
Symptoms are usually worse in the morning and improve throughout the
day.
An abnormal connection between the middle and inner ear spaces. Patients typi -
cally present with symptoms of unilateral hearing loss, tinnitus, dizziness, dys
equilibrium, and ~ertigo.'~
Injury to the cervical vertebrae or associated soft tissue caused by a sudden for-
ward or backward acceleration of the vertebral co1umn.l
TABLE 2. Common vestibular laboratory tests that may be performed on persons with cervicogenic dizziness.
Vestibular test
Description of the test
Criteria for a normal result
Oculomotor screening5J4 Patients are asked to sit in an otherwise darkened room, The accuracy and timing of the
fixate on a target, and watch vertical lines move in
eye movements are compared
front of them. The electronystagmography (ENG) elec-
with normative data.
trodes that surround the eyes record eye movements.
Abnormal responses may indicate central nervous sys-
tem dysfunction.
Calor ic te~ t i r igs l~. ~~
For horizontal canal testing, patients are placed in the The symmetry and intensity of
supine position with their head flexed 30 . Warm or
the eye movements are com-
cold air or water is placed in the ear canal alternately
pared with normative data.
while the ENG electrodes record eye movements. This
is the only test that can localize the side of the lesion
in the ear.
Positional testing5J4
Patients are asked to l ie supine with their head turned to
Nystagmus is not normally seen
the right and left and also to lie completely on their
in persons without vestibular
left and right sides. The eye movements are recorded
dysfunction.
in each position in darkness.
Rotational test inpa
Patients sit in a darkened room whi le they are moved
The examiner determines the
slowly to the right and le ft in a ro tating chair. Eye
symmetry and intensity of the
movements are recorded. This test assesses the vestibu-
response from the recordings
lo-ocular reflex.
and compares it to normative
data.
P o ~ t u r o g r a p h y ~ ~ , ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
he patient stands on a forceplate dur ing 6 increasingly
Patient's scores are compared to
complex visual and somato-sensory conditions (Senso-
age-related normative scores.
ry organization testing). The forceplate records the
amount of sway that the patient experiences. Postural
sway is also assessed during linear and angular pertur-
bations of the platform.
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produced nystagmus and ataxia. In humans, injecting
anesthetic around the cervical dorsal roots caused dys-
equilibrium, a strong sensation of imbalance and be-
ing pulled towards the side of the injection. Wap
neri4 discovered that the sensation of tilting or fall-
ing could also be evoked by electrical stimulation to
the cervical muscles. Accordingly, the aberrant input
from the cervical proprioceptors is considered to be
related to muscle spasms in the sternocleidomastoid
and upper trapezius muscle^.^^.^.^.^^ Hence, this evi-
dence leads to the current theory that cervicogenic
dizziness results from abnormal input into the vestib-
ular nuclei from the proprioceptors of the upper cer-
vical region. Furthermore, the interconnections be-
tween the cervical proprioceptors and the vestibular
nuclei may contribute to a cyclic att tern,^ such that
cervical muscle spasms contribute to dizziness and
dizziness contributes to muscle spasm, although the
causal relationship is unclear.
DIAGNOSTIC CRITERIA
Cervicogenic dizziness is a diagnosis of exclusion
(ie, the diagnosis is usually based on the elimination
of the othe r competing diagnoses, such
as
vestibular
or central nervous system pathologies). The develop
ment of a robust clinical diagnostic test for cervico-
genic dizziness has been elusive. The neck torsion
nystagmus test, or head-fixed, body-turned maneuver
is considered by some to identify cervicogenic dizzi-
ness." This test requires the head of the patient to
be stabilized while the body is rotated under-
neath. '"% Theoretically, the neck proprioceptors are
stimulated while the inner ear structures remain at
their resting ~ t a t e . ~ystagmus is elicited in a posi-
tive test. However, this test has not been demonstrat-
ed to be specific for cervicogenic dizziness. Ooster-
veld et alx' reported that 64% of 262 patients with
neck pain who presented to an otolaryngology de-
partment post-whiplash had nystagmus elicited with
the head-fixed, body-turned maneuver. On the other
hand, it has been demonstrated that up to 50% of
subjects without cervical spine pathology have also
demonstrated nystagmus with the head-fixed, body-
turned m a n e ~ v e r . ~ ~ , " ~ . ~ ~positive response (nystag-
mus) may not indicate pathology, but may instead be
a manifestation of the cervical ocular reflex.%
Others have explored the use of vestibular and
postural sway testing for the diagnosis of cervicogen-
ic dizziness. Tjell and Rosenhallio examined smooth
pursuit eye movements in patients with whiplash,
acute vestibular pathology, or central nervous system
dysfunction. Based on reduced velocity of eye move-
ments during the tracking tasks when the subjects'
heads were turned, the researchers were able to clas-
sify the individuals who had dizziness post-whiplash
with a sensitivity of 90% and specificity of 91%. In
addition, evidence of increased postural sway in s u b
jects with whiplash-associated disorder o r other cervi-
cal dysfunction has led some to consider using postu-
rography as a diagnostic t e ~ t . ~ . ~ . ~ ~ ~ ~ ~ ~ ~ W o
these tests cannot be performed in the clinic without
specialized equipment and have not been validated.
Furthermore, increased postural sway is a nonspecific
finding that is also evident in patients with vestibular
injury.'
The lack of a definitive diagnostic test increases
the challenge of diagnosing cervicogenic dizziness.
Therefore, the diagnosis of cervicogenic dizziness is
suggested by
(1) a close temporal relationship be-
tween neck pain and symptoms of dizziness, includ-
ing time of onset and occurrence of episodes, 2)
previous neck injury or pathology, and (3) elimina-
tion of other causes of dizziness.% It is important to
take a detailed history and perform a comprehensive
examination in order to eliminate other causes of
dizziness. The details of the history and physical ex-
amination are discussed below.
PHYSICAL THERAPY EVALUATION
Patient History
When a physician refers a patient to physical thera-
py, the referral may or may not provide a direction
for the history taking. Certainly, a referral for "dizzi-
ness, evaluate and treat" by a primary care physician
would not be as helpful as one for "cervicogenic diz-
ziness, evaluate and treat" by an otolaryngologist or
neurologist. Furthermore, one would expect a more
thorough screening procedure for vestibular or cen-
tral nervous system disorders by the physicians spe-
cializing in inner ear disorders. Since not all thera-
pists have the benefit of receiving referrals from
these specialists, this article assumes that the only in-
formation provided to the therapist is from the pa-
tient. Furthermore, because of the imprecise use of
the terms dizziness and vertigo in the general com-
munity, we will approach the patient with no precon-
ceived notions about the qualitative nature of the pa-
tient's symptoms.
Obtaining a thorough history from a patient pre-
senting with dizziness is critical to making a decision
regarding the proper care of the patient. The first
step is to ask the patient to describe their symptoms.
Unfortunately, there are many words used to de-
scribe symptoms of dizziness and vertigo, and it is of-
ten difficult for a patient to provide specific descrip
tions. Table 3 includes some typical ways that pa-
tients describe their symptoms. If a patient's de scrip
tion of their symptoms is consistent with vertigo,
then a central o r peripheral vestibular disorder is
suspected. However, cervicogenic dizziness cannot be
completely ruled out as a diagnosis.
The duration and frequency of the symptoms, as
well as their temporal relationship with the neck
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T BLE
3
Common words used to describe symptoms of patients presenting with balance and vestibular disorders.
Patient s words What the words suggest
Dizziness
Spinning
Headache
My neck hurts.
People tell me that my head is not straight.
I
eel like
I
am going to fall.
I
can t walk straight.
I
am having trouble reading.
I am tired.
I
eel like everything is moving when
I
am in a busy
environment with motion and distractions.
My vision is jumping.
Swimming sensation in their head
This is a nonspecific finding and could be either cewicogenic dizziness or a
peripheral or central vestibular disorder.
The patient could have a central or peripheral vestibular disorder, although
spinning of short duration often suggests Benign Paroxysmal Positional Verti-
go (BPPV) if there is no central nervous system dysfunction.
Often patients complain of an occipital or bitemporal headache with cewico-
genic dizziness. Tension headaches are more localized and are described as
a ring around the head or in the frontal area. Migraines can be very severe,
tend to be unilateral, and may cause sensitivity to light and motion.
It is often seen i n people wi th whiplash or labyrinthine concussion disorders.
This is more common in central vestibular disorders than peripheral disor-
ders.
This is often seen in ce~icogenic izziness and also with head trauma. This is
rarely seen i n persons wi th peripheral vestibular disorders.
This is common in both cewicogenic dizziness and in peripheral or central
vestibular disorders. It is a nonspecific symptom.
This could be seen in cewicogenic dizziness, with a peripheral vestibular dis-
order, or wi th central vestibular disorder.
This is also a nonspecific symptom. It could be cewicogenic dizziness or a
peripheral or central vestibular disorder. I t might be he lpful to test their eyes
with a vision chart to
see
if there is any loss of acuity. If the problem exists
only wi th head movement, it may suggest a vestibular abnormality.
This is a very common complaint in persons with vestibular or balance disor-
ders.
This complaint of space and motion discomfort is common in persons with
migraine, anxiety-panic, and i n persons with peripheral vestibular disorders.
The visual surroundings wi ll jump with oscillopsia and i t usually suggests a
peripheral vestibular disorder of either 1 or both ears.
Nonspecific but can suggest that there is central nervous system dysfunction.
pain, can aid in the diagnosis of cervicogenic dizzi-
ness. The time how long ago) and mode of onset
gradual, sudden , or associated with injury) should
be determined. Symptoms resulting from cervicogen-
ic dizziness typically are associated with injury or cer-
vical spine disease, however, their onset may be sud-
den or gradual and occur days to years following the
injury. Next, if the dizziness is episodic, the number
of events per day or week and the duration of each
event should be elicited by the therapist. Table
4
lists
the frequency and duration expected for various
causes of dizziness. Cervicogenic dizziness typically
occurs in episodes lasting minutes to hours. Informa-
tion regarding conditions that exacerbate or relieve
the symptoms is also helpful. Symptoms resulting
from cervicogenic dizziness will be increased with
neck movements or neck pain and decreased with in-
terventions that relieve neck pain modalities, anal-
gesic, anti-inflammatory or muscle relaxant medica-
tion). Finally, the therapist should ask the patient for
any history of balance difficulties and falls related to
the symptoms.
similar type of history regarding neck pain
should be obtained, including a specific description
of symptoms, location, time and mode of onset, and
aggravating factors. Dizziness related to active move-
ment or changes in head position with or without
neck pain may lead one to think that there is a cervi-
cal component. To entertain a diagnosis of cervico-
genic dizziness, however, the therapist must be able
to correlate the onset and duration of the dizziness
symptoms with the neck dysfunction ie, dizziness ac-
companied by neck pain o r with head movements).
In addition to the complaints about dizziness and
T BLE
4
Duration and frequency of common causes of dizziness.
Cause Common symptoms Frequency Duration Related factors
Benign Paroxysmal Positional Vertigo4 Vertigo Episodic Seconds Related to head position,
usually worse in
AM
Cewicogenic d i z ~ i n e s s ~ ~ . ~ ~ Dizziness, dysequilibrium Episodic Minutes to hours Related to head position
Perilymphatic fistula16 Dysequilibrium, vertigo
Episodic Seconds to minutes Vertigo during Valsalva
maneuver
Labyrin thine concussion42 Vertigo, dysequil ibrium Episodic Hours to days Increases wi th fatigue
Central vestibular dys fun c t i~ n~~ Dizziness, dysequilibrium More constant Days to weeks May be seen in combi-
nation with inner ear
~atholoeies
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TABLE 5.
The appropriate action to
be
taken by a physical therapist based on various additional symptoms in patients presenting with dizziness or
vertigo.
Unexplained or new onset of
Symptoms that require
Symptoms that can be
symptoms that may require
nonemergent referral to
treated by a physical
immediate medical attention an ot ol a~ n~ ol oa is t therapist
Constant vertigo Constant dizziness Transient dizziness
Feeling of be ing pushed to one side
Unilateral hearing loss
Cervical pain
Facial asymmetry
New onset of tinnitus
Limited cervical range of motion
Swallowing dysfunction
Aural fullness stuffiness in ear)
Radicular upper extremity symptoms
Speech problems Ear pain Headache
Oculomotor dysfunction cran ial Transient vertigo Balance complaints
nerves Ill, IV, VI)
Jaw pain
Rosis Visual sensitivity
Vertical nystagmus Nausealvomiting*
Loss of consciousness
Anxiety, fatigue*
Repeated, unexp lained falls
Changes in sensation
Severe headache
Upper motor neuron signs and
symptoms
Although physical therapists may not provide direct intervention for these symptoms, reduction in dizziness may alleviate them.
neck dysfunction, the therapist should be careful to
ask further questions regarding other symptoms that
may be perceived by the patient, as listed in Table
5.
All the symptoms in the first column of Table 5 sug-
gest a possible central nervous system pathology that
may need immediate attention. It is always preferable
to speak with the patient's primary care or referring
physician before seeking emergen t care. Symptoms
listed in the second column of Table 5 (which are
frequently reported after sustaining a whiplash inju-
ry) require a visit to an otolaryngologist because they
are consistent with inner ear pathology. In our opin-
ion, these symptoms do not require urgent attention.
Finally, the third column lists typical secondary sym p
toms that may be reported at the time of the initial
evaluation. We believe that these symptoms are with-
in the scope of physical therapist practice and thus
may be addressed directly.
If a patient experiences transient true vertigo, then
a peripheral vestibular ailment or benign paroxysmal
positional vertigo is more likely. The time course of
the symptoms also may provide a clue to the patholo-
gy. Dizziness or vertigo due to perilymphatic fistula
may have an onset
24-72
hours after head trauma
and episodes may last minutes to hours.%. Nausea
and vomiting are common signs of acute vestibular
pathology. Benign paroxysmal positional vertigo may
occur more than 2 weeks after head t r a ~ m a ; ~nd
characteristically lasts less than a minute after a
change in position.47 Cervicogenic dizziness may oc-
cur anywhere from days to months or longer after an
injury of the head and neckFOwith a time course of
minutes to hours per episode.
Examination
Once the history is complete, the therapist can
proceed to ru le in o r out the competing differential
diagnoses. Note that the examination procedure pre-
sented here does not represent the complete exam a
vestibular rehabilitation specialist would use for any
patient presenting with nonspecific dizziness,' nor
does it represent the complete exam that an ortho-
paedic physical therapy specialist would use for a pa-
tient with nonspecific cervical dysf~nction.~%ther,
it is an outline of a thorough examination the au-
thors would use to rule in or out a diagnosis of cervi-
cogenic dizziness. The order in which the assess-
ments are performed is at the discretion of the ther-
apist, but an attempt was made to discuss the exami-
nation in a logical sequence.
The flow chart (Figure) depicts the decision-mak-
ing process that the physical therapist should go
through to arrive at a diagnosis of cervicogenic dizzi-
ness or oth er pathology that may present similarly to
cervicogenic dizziness. In the first step, the therapist
determines if the patient with a chief complaint of
dizziness or vertigo has neck pain, e ither at rest, with
active neck movement, or with palpation of the neck
musculature. This step is important because, by defi-
nition, a diagnosis of cervicogenic dizziness is exclud-
ed in a patient without neck pain.' If the patient has
dizziness with neck pain, a diagnosis of cervicogenic
dizziness should be considered because cervicogenic
dizziness might account for both the dizziness and
the neck pain. However, there is a possibility that the
patient may have neck pain as a secondary impair-
ment due to a vestibular disorder or may have s e p
arate diagnoses,
1
to account for the dizziness and
1
to account for the neck pain. To help establish a di-
agnosis of cervicogenic dizziness, other vestibular dis-
orders such as benign paroxysmal positional vertigo,
Meniere's disease, labyrinthine concussion, and mi-
graine-related vestibulopathy must be ruled out. Al-
though the sensitivity and specificity of vestibular
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/ injury or patholog/
no
PPV , vestibular disorder,
andlor cewicogenic di n i
I
Dix-Hallpike
L J
no
Vestibular disorder, andlor
Canalith
-
epositioning
Maneuver
cewicogenic dizziness
vestibular testing
Vestibular
disorder
and refer to M D for
normal results
Co-treat Case 1)
FIGURE.
Decision tree
used
for
a
~atientwho Dresents with dizziness or vertigo and neck pain. PW indicates benign paroxysmal positional vertigo;
MD, medical doctor; VR-PT, vestibhar rehabilitition physical therapist.
function tests are not
v ry high,4.%14.17.X'-3'II~ l.40.7.9
the
use of vestibular function tests in conjunction with
history and clinical examination provides the clini-
cian with a reasonable idea of the involvement of the
vestibular system.
In the early part of the examination, the therapist
should measure the patient's active cervical range of
motion, preferably while the patient is sitting. This is
done for several reasons. The first is to simply mea-
sure any impairment in the range of motion. Sec-
ond, the therapist should inquire about any symp
toms of pain or dizziness elicited by the active move-
ments. Changes in pain or dizziness can be quanti-
fied by comparing the patient's ra ting of these
symptoms with the rating obtained before move-
ment. Third, the active movement can be used to de-
termine if the patient has adequate range of motion
for subsequent tests that the therapist may perform,
such as the Dix-Hallpike maneuver for benign parox-
ysmal positional vertigo (BPPV), which requires
30"
of cervical extension a nd 45" of cervical rotation.:
With the patient sitting, the therapist may also per-
form vision tests and an upper quarter screening
procedure (range of motion, manual muscle testing,
accessory motion testing, sensation and reflex testing
of the upper extremity and cervical region).
The therapist may test for posterior semicircular
canal BPPV using the Dix-Hallpike mane~ver.~-' he
therapist must make certain that the patient has ade-
quate active range of motion, given that the cervical
spine of the patient is placed in
45"
of rotation and
30" of extension so that the posterior semicircular ca-
nal is stimulated in the vertical plane. The Dix-Hall-
pike maneuver is initiated by having the patient at-
tain the long-sitting position while the therapist rotates
the patient's head 45" to one side and brings the pa-
tient into supine quickly while extending the head
30". The patient is asked to report any symptoms
while the therapist observes the patient's eyes for
nystagmus. If the patient cannot tolerate a traditional
Dix-Hallpike maneuver because of pain or decreased
cervical range of motion, the position can be modi-
J
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fied by having the patient lie down to the side with
the head turned so the back of the head is toward
the surface and the nose is pointing up. Tilt tables
or mobilization tables can be used to put the patient
in a position to stimulate the posterior semicircular
canal by having the patient rotate the head approxi-
mately 45' to the side and lowering the head of the
bed into a trendelenberg position. A Dix-Hallpike
maneuver is said to be positive if the patient reports
symptoms of spinning and rotational, upbeating nys-
tagmus is observed with a latency of 5-15 seconds
and a duration of 30 seconds to 1 minute. If the Dix-
Hallpike maneuver is positive, BPPV can be treated
by performing a canalith repositioning maneuverw
or by instructing the patient in Brandt-Daroff exercis-
es.' A single treatment of the canalith repositioning
maneuver has been reported to eliminate symptoms
in 72-78% of patients with BPPV, with complete res-
olution of 91% after 2 treatment^.^^.^^.^^.^^.^ However,
only one randomized controlled clinical trial has
been performed. Brandt-Daroff exercises have been
reported to result in a remission of symptoms in
98% of patients when performed over a 2-week peri-
od] no randomized controlled clinic trial has been
performed to confirm this. If the therapist is not
skilled in these interventions, then referring the pa-
tient to a physical therapist o r physician specializing
in balance disorders is appropriate.
A negative Dix-Hallpike maneuver should lead to
management of the neck impairments and referral
to a physician for vestibular testing. The diagnosis of
cervicogenic dizziness is then made only after no ves-
tibular abnormalities are found by the physician.
Considering either diagnosis, the therapist may de-
cide to cotreat with, or refer to, a vestibular rehabili-
tation physical therapist.
Patients with cervicogenic dizziness may complain
of poor balance. Balance disorders may be manifest-
ed by difficulties in standing with a narrow base of
support, walking with head turns, reaching outside
the base of support, turning and looking over one's
shoulder, standing o r walking on compliant surfaces.
decreased environmental lighting, and eye closure. A
full balance assessment may include pen and paper
tests such as the Activities-specific Balance Confi-
dence scale?* as well as functional tests like the Dy-
namic Gait Indexm and the Berg Balance Test.13 The
Clinical Test for Sensory Interaction in Balance
(CTSIB) is another popular test that is used to assess
the patient's ability to use vestibular cues while con-
flicting visual and proprioceptive cues are present-
ed.'j7
PHYSICAL THERAPY INTERVENTION
Historically, the intervention for cervicogenic dizzi-
ness has included manual therapy (mobilization and
manipulation), mechanical traction, physical modali-
ties, postural reeducation, active range of motion,
massage, balance retraining, trigger point injection,
muscle relaxants, and use of a soft cervical collar
during the acute
phase.lfi.20. 2~26~27.M.44.5 .65.M~77
HOweV-
er, few controlled clinical trials have been performed
to determine the effectiveness of these interventions.
Three clinical trials that propose intervention for
cervicogenic dizziness are summarized in Table 6.
These authors report that 7342% of patients receiv-
ing some form of manual therapy had a reduction in
their symptom^.^ ^'.^^ It is the authors' experience
that patients may require both manual therapy and
vestibular rehabilitation to achieve relief of both cer-
vical and vestibular symptoms.
Two case reports will be used to illustrate the diag-
nosis and treatment of suspected cervicogenic dizzi-
ness. One case report describes a patient who was
successfully treated using a combination of both
manual therapy and vestibular rehabilitation (Case
1). The second case report describes a patient initial-
ly evaluated by an orthopaedic physical therapist and
given cervical spine range of motion exercises and
subsequently treated with vestibular rehabilitation
therapy alone (Case 2).
Case 1
The first patient is a 49-year-old woman who pre-
sented with complaints of dizziness, nausea, and dyse-
quilibrium 8 months after a motor vehicle accident.
She described fluctuating symptoms that occurred
daily. Th e symptoms were exacerbated by head rnove-
ments o r with lying down and would last for hours.
She related that the symptoms were worse on days
when the neck pain and headaches were worse. She
denied any tinnitus, aural fullness, or hearing loss.
Vestibular function testing results including electronys-
tagmography
(ENG) ,
calorics, positional testing and
rotational chair, provided by the physician, were nor-
mal.
On initial evaluation, she rated her neck pain as
8-9/10 on a verbal analog scale with 0 meaning no
pain and 10 meaning the worst imaginable pain. Her
cervical range of motion was not impaired; however,
any head or neck movements increased her symp
toms of dizziness. She presented with tenderness to
palpation and palpable trigger points (areas of in-
creased pain) in her bilateral upper trapezius, scale-
nes, and sternocleidomastoid muscles. She dernon-
strated an inability to maintain focus on an object
while turning her head (impaired functional use of
the vestibular-ocular reflex) and complained of in-
creased nausea during activities that required head
and eye movement. During static balance testing, she
was able to maintain stance with feet together for
6
seconds with her eyes open, but was unable to main-
tain the position with her eyes closed. She was una-
ble to maintain tandem stance (sharpened Romberg)
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TABLE
6. Summary of articles that address outcome of treatment for cervicogenic dizziness.
Study
Wing and Hatgrave-Wilson,
974n
Karlberg
t
al,
199652
Calm
et
al.
1998
Subjects
Control group
Type of study
Neurodo logic evaluation
Intervention
Frequency and duration
Outcome measures
Results
80 subjects with history of neck
pain and vertigo,
46%
with
neck injury.
None.
Case series.
96%
had normal ear, nose, and
throat examination,
80%
had
normal electronystagmography
examination including caloric
and positional testing.
Manipulation, immobilization in
soft cervical collar, instruction
in proper sleeping positions.
Not specified.
Ear, nose, and throat with head
flexed, extended or rotated
with eyes open and closed;
subjective report of symptom
relief.
73%
of patients demonstrated
improvements in ear, nose,
and throat with head and neck
movements.
53%
of patients
reported complete relief of al l
symptoms.
36%
had signifi-
cant improvement and re-
turned to normal activity with-
out medication.
17
patients, mean age
37
years, with diagno-
sis of cervicogenic dizziness. Subjects ran-
domized to receive immediate ~hvsical
therapy or wait
2
months and i k a t e phys-
ical therapy.
17 healthy subjects.
Prospective, randomized, c linical t rial.
Ear, nose, and throat and neurologica l exam
excluded extra-cervical causes of dizzi-
ness.
oft
tissue treatment, stabilization exercises
of the trunk and cervical spine, passive
and active range of mot ion exercises, re-
laxation techniques, home training pro-
grams, and minor ergonomic changes at
work.
5-20
weeks with median number of visits =
13.
Subjective intensity of neck pain; intensity
and frequency of dizziness; variance of vi -
bration and galvanic-induced body sway.
There was no change i n symptoms of neck
pain or dizziness between the time when
initially tested and just prior to beginning
physical therapy, for the group that started
treatment late.
82%
of ~atients e~orted
improvement of dizzi nks followi;lg physi-
cal therapy.
82%
of patients reported im-
provement of neck symptoms. Postural per-
formance significantly improved following
phvsical theraw P
.05).
50
patients with suspected cervi-
cogenic dizziness, 31 patients
with cervical spine dysfunction
(groupA) and
19
patients
without cervical spine dys-
function (group B).
None.
Case series.
Ear, nose, and throat and neuro-
logical exam excluded extra-
cervical causes of dizziness.
Both groups treated with manual
therapy.
Intensive outpatient physical
therapy for up to
3
months.
Subjective improvement in dizzi-
ness.
Group
A: 77.4%
reported im-
provement of symptoms of
dizziness; patients complete-
ly free of dizziness. Group B:
26.3%
reported improvement
of symptoms; none were com-
pletely free of symptoms.
or single limb stance without uppe r extremity s u p
port. On the sensory organization test of computer-
ized dynamic posturography, she demonstrated a pat-
tern of multisensory dysfunction. Her composite
score was 19/100 (normal for her age would be 70/
100) with increased sway in conditions 1-3 and falls
on all trials of conditions 4 43 (for additional infor-
mation about posturography test conditions, refer to
Furman ). She demonstrated ataxic gait with her
eyes open and closed.
The patient was given a diagnosis of cervicogenic
dizziness based on the association between her symp
toms of dizziness and neck pain, history of a flexion-
extension injury of the cervical region, and the ex-
clusion of other peripheral vestibular pathology. She
was initially seen weekly for physical therapy and
treated with soft tissue massage, mobilization, and
deep massage to her cervical musculature with em-
phasis on massaging the trigger points in the sterno-
cleidomastoid muscle. She was instructed in a home
exercise program of gentle range of motion exercis-
es, followed by application of ice to be performed
2
4 times each day. In addition, she was provided a
transcutaneous electrical nerve stimulation (TENS)
unit and instructed in its use to provide pain relief
and to decrease the spasms in the cervical muscles.
She was also instructed to begin a progressive walk-
ing program and to perform simple balance activities
such as standing with the eyes closed and standing
feet together with small amounts of sway.
At the end of 3 weeks, the patient reported that
her pain level had decreased from 8-9/10 to 3/10
on a verbal analog scale more than 50% of time. She
reported only a single episode of dizziness and nau-
sea in the previous week. She demonstrated signifi-
cant improvement in the static balance tests. She
demonstrated no veering while walking with head
turns or while walking with her eyes closed. Al
though she demonstrated significant improvements
in pain control and balance, she continued to de-
scribe dizziness and nausea with head turns, standing
or moving with her eyes closed, with movement in
the environment o r with conflicting visual cues (ie,
walking in store aisles or in environments with busy
patterns on the floor or walls). Due to these syrnp
toms of dizziness and the finding of gaze instability
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at initial evaluation, it was decided to begin vestibu-
lar rehabilitation to decrease her reliance on visual
and somatosensory cues and increase her use of ves-
tibular cues for balance. The vestibular rehabilitation
program consisted of eye exercises (VORxl and
VORx2) to improve the efficacy of the vestibular-ocu-
lar reflex and balance exercises with graded expo-
sure to varied sensory
The patient was seen for 17 visits over a period of
5 months. At discharge, she reported that she was
close to 100% of he r premorbid function. She con-
tinued to complain of left occipital pain and mild
dizziness with quick movements and visual conflict.
She reported her pain level was less than 2/10 on a
verbal analog scale
90%
of the time. On evaluation,
cervical range of motion and strength were not im-
paired and she was able to perform the static bal-
ance tests (Romberg, sharpened Romberg, and sin-
gle limb stance) for at least 30 seconds with her eyes
open and closed. Her computerized dynamic postu-
rography score had also improved to within normal
limits, with a composite score of 81/100 and normal
amounts of sway on all
6
conditions of the sensory
organization test. She was able to ambulate commu-
nity distances (distances of 1-2 miles) without assis-
tance and with no evidence of sway.
Case
The patient is a 49-year-old female who experi-
enced a motor vehicle accident that resulted in a
flexionextension injury of the cervical region one
year ago. She was referred to an outpatient ortho-
paedic clinic with a diagnosis of neck pain and dizzi-
ness. The patient's chief complaint was of dizziness
and imbalance, which she related to changes in head
position. She had only 25% of normal cervical flex-
ion, extension, right side bending, and right rota-
tion. She also had approximately 50% of normal
range of motion for left side bending and left rota-
tion. The orthopaedic therapist saw the patient for 1
visit and provided her with neck stretching exercises
in an attempt to increase her range of motion and
then referred her to vestibular rehabilitation.
The patient stated that she previously had experi-
enced an acute onset of vertigo but had not been
vertiginous for several months. Her Activities-specific
Balance Confidence scale (ABC) score was only 27%,
indicating that the patient perceived that she was not
confident with her balance (100% is the best score
that can be achieved). The ABC is a tool used to as-
sess confidence in 16 different activities of daily liv-
ing and has been used with persons with vestibular
dys f~nction. ~ he patient's Dizziness Handicap In-
v en to ry (DHI) score was 66. Scores range from
zero to 100. score of zero indicates no symptoms.
The DHI measures perceived handicapping effects of
dizziness. A score of 66, in our experience, reflects
severe symptoms.
The patient had normal strength, sensation, and
deep tendon reflexes in all extremities. At baseline,
the patient's dizziness symptoms were 50/100 based
on a verbal analog scale (higher scores indicate
greater perceived dizziness). She related a mild in-
crease in symptoms during head movements with her
eyes open and closed. Her dynamic posturography
score was normal for the Sensory Organization Test.
Th e patient's Dynamic Gait Index score was 20/24. A
score of 24/24 would be considered normal for her
age.m The therapist attempted to perform the Dix-
Hallpike maneuver in order to rule out BPPV, but
the patient was unable to tolerate the position be-
cause of nausea.
It was believed that the patient had symptoms con-
sistent with cervicogenic dizziness based on her flex-
ionextension injury, correlation of symptoms with
head movements and neck pain and the exclusion of
a peripheral vestibular diagnosis based on normal
performance on vestibular function testing (electro-
nystagmography, caloric, positional and rotational
vestibular testing). Due to the patient's complaints of
dizziness, dysequilibrium, and her lack of confidence
in performing upright activities it was believed she
would benefit from a rehabilitation program that
would retrain her ability to use various balance strat-
egies during functional activities. The patient was
provided with a home exercise program that empha-
sized walking, standing and performing head move-
ments, rolling to the right and left, and standing
with eyes closed.
She was seen for 2 additional visits, 2 weeks apart.
During her fourth visit to physical therapy 2 months
after her initial evaluation, her
ABC
score had in-
creased to 70% and her DHI had decreased to 40/
100. The patient was not complaining of any symp
toms at baseline and the DGI increased to 23/24.
However, she continued to have an increase in symp
toms while shopping and in busy visual environ-
ments. She had no symptoms while working. The pa-
tient was satisfied with the outcome of her therapy
and was discharged.
CONCLUSION
Cervicogenic dizziness is a diagnosis characterized
by dizziness and dysequilibrium that is associated
with neck pain in patients with cervical pathology.
The curren t literature on this topic is limited with
respect to the number and quality of the clinical
ui
als reported. The diagnosis is dependent o n correlat-
ing symptoms of imbalance and dizziness with neck
pain and excluding other vestibular disorders on the
basis of history, examination, and vestibular function
tests. When diagnosed correctly, we believe that cer-
vicogenic dizziness can be successfully treated using a
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combinatio n o f manual therapy and vestibular reha-
bilitation.
Man ual therapy is recommended treatment for
cervicogenic dizziness directed at decreasing muscle
spasms and trigger points o f pai n in the cervical
musculature. In the f irst case presented, a lthough
the patient's n eck pai n an d balance appeared to im-
prove with manu al therapy, i t was no t until she was
also given vestibular rehabil itati on exercises that the
symptoms o f dizziness improved.
In
the second case,
the patient improved with a hom e exercise program
that addressed cervical range o f m ot io n and balance.
Fro m our clin ical experience, we recom mend that
cervicogenic dizziness be treated wi th m anua l thera-
py t o decrease the irrita tion o n the cervical proprio-
ceptors fr om muscle spasms an d trigger points, an d
exercises
with
graded exposure t o sensory i nput s to
improve the patient's use o f vestibular and pro prio-
ceptive inputs for balance.
In
addition, we recom-
me nd eye exercises to impro ve the func tion o f the
vestibular-ocular reflex.
In
orde r t o fully address all
o f the patient's symptoms, i t may be necessary for
the orthopaedic an d vestibular specialists to treat the
patient together.
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