cervicogenic dizziness

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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-

C o p y r i g h t © 2 0 0 0 J o u r n a l o f O r t h o p a e d i c & S

p o r t s

P h y s i c a l T h e r a p y ® . A l l r i g h t s r e s e r v e d .


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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-

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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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