CERVICOGENIC DIZZINESS

Definition: Cervicogenic dizziness a nonspecific sensation of altered

orientation in space and dysequilibrium originating from abnormal afferent activity from the neck." Cervicogenic dizziness does not result from vestibular dysfunction and, therefore, rarely results in true vertigo.' Cervicogenic dizziness is most often associated with flexion-extension injuries and has been reported in patients with severe cervical arthritis, herniated cervical disks, and head trauma. In these patients, complaints of ataxia, unsteadiness of gait, or postural imbalance associated with neck pain, limited neck range of motion, or headache predominate. When diagnosed and treated properly, the symptoms of cervicogenic dizziness can be reduced, resulting in improved function.

INCIDENCE AND PREVALENCE:

The concurrence of dizziness complaints and cervical 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 injury significant disability can result, with an estimated 20% of individuals who experience whiplash requiring 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 whiplash. The next most common symptom is headache (primarily occipital in location), which occurs in 67% of the study population. Although dizziness, vertigo, and dysequilibrium do 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 symptoms.58.64.71. Vestibular system disorders are included in the differential diagnosis of patients with dizziness associated with cervical spine dysfunction. For example, dizziness following neck injury may be due to vestibular system pathologies, brain injury, or cervicogenic dizziness several groups have examined the occurrence of vestibular disorders following whiplash. Reports of dizziness with other types of neck dysfunction are certainly not as prevalent as with whiplash. However, several case reports have demonstrated dizziness in patients with cervical

spine spondylosis and cervical muscle spasms. Ryan and CopeGS reported 3 cases of dizziness that they attributed to cervical spondylosis. The symptoms of 3 patients with dizziness and painful posterior cervical muscles reduced with an injection of anesthetic into the posterior neck muscles .Cervicogenic dizziness may be a result of whiplash injury, other forms of cervical spine dysfunction, or spasms in the cervical muscles

HISTORICAL BASIS AND PATHOPHYSIOLOGY OF CERVICOGENIC DIZZINESS:

Brown2" relates that the contribution of the cervical region to balance has been studied experimentally 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 balance, and postural adjustments. Brownz0 provides a comprehensive review of this literature. With strong connections between the cervical receptors and balance function, it is understandable that injury or pathology of the neck may be associated with a sense of dizziness or dysequilibrium. Dizziness that is presumed to occur due to dysfunction in the cervical spine has been recognized since early in the 20th century. Symptoms of cervicogenic 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 experimentally induced dizziness, tinnitus, and Horner's syndrome (constriction of the pupil, ptosis, and ipsilateral loss of sweating) by injecting anesthetic into the upper cervical region. No sympathetic or vascular changes were subsequently identified that could account 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 region Ryan and Cope" introduced the term "cervical vertigo" and although vertigo is rarely a symptom, cervical vertigo has remained the most popular name for the focus of Ryan and Cope's paper. These authors theorized that cervicogenic dizziness was due to abnormal afferent input to the vestibular nucleus from damaged joint receptors in the upper cervical region. They described 3 types of patients that display this syndrome: patients with cervical spondylosis, patients treated with cervical traction, and patients following neck trauma. Graf4 found that he could relieve 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 dysequilibrium. Others have experimentally produced a "reversible" lesion in the cervical region and observed deficits in balance and vision. CohenZJ described deficits in balance, orientation, and coordination in primates following injection of anesthetic in the upper 3 cervical 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 produced nystagmus and ataxia. In humans, injecting anesthetic around the cervical dorsal roots caused disequilibrium, a strong sensation of imbalance and being pulled towards the side of the injection. Wapneri4 discovered that the sensation of tilting or falling 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 evidence leads to the current theory that cervicogenic dizziness results from abnormal input into the vestibular nuclei from the proprioceptors of the upper cervical region. Furthermore, the interconnections between the cervical proprioceptors and the vestibular nuclei may contribute to a cyclic pattern 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 (i.e., the diagnosis is usually based on the elimination of the other competing diagnoses, such as vestibular or central nervous system pathologies). The development of a robust clinical diagnostic test for cervicogenic dizziness has been elusive. The neck torsion nystagmus test or head-fixed, body-turned maneuver is considered by some to identify cervicogenic dizziness." This test requires the head of the patient to be stabilized while the body is rotated underneath. Theoretically, the neck proprioceptors are stimulated while the inner ear structures remain at their resting. Nystagmus is elicited in a positive test. However, this test has not been demonstrated to be specific for cervicogenic dizziness. Oosterveld et alx' reported that 64% of 262 patients with neck pain who presented to an otolaryngology department 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, bodyturned maneuver. A positive response (nystagmus) 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 cervicogenic 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 movements during the tracking tasks when the subjects' heads were turned, the researchers were able to classify the individuals who had dizziness post-whiplash with a sensitivity of 90% and specificity of 91%. In addition, evidence of increased postural sway in subjects with whiplashassociated disorder or other cervical dysfunction has led some to consider using posturography as a diagnostic test. However 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 between neck pain and symptoms of dizziness, including time of onset and occurrence of episodes, (2) previous neck injury or pathology, and (3) elimination 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.

PHYSICAL THERAPY EVALUATION: Patient History

When a physician refers a patient to physical therapy, the referral may or may not provide a direction for the history taking. Certainly, a referral for "dizziness, evaluate and treat" by a primary care physician would not be as helpful as one for "cervicogenic dizziness, evaluate and treat" by an otolaryngologist or neurologist. Furthermore, one would expect a more thorough screening procedure for vestibular or central nervous system disorders by the physicians specializing in inner ear disorders. Since not all therapists have the benefit of receiving referrals from these specialists, this article assumes that the only information provided to the therapist is from the patient. Furthermore, because of the imprecise use of the terms dizziness

and vertigo in the general community, we will approach the patient with no preconceived notions about the qualitative nature of the patient's symptoms. Obtaining a thorough history from a patient presenting 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 describe symptoms of dizziness and vertigo, and it is often difficult for a patient to provide specific descriptions. If a patient's description of their symptoms is consistent with vertigo, then a central or 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 pain, can aid in the diagnosis of cervicogenic dizziness. The time (how long ago) and mode of onset (gradual, sudden, or associated with injury) should be determined. Symptoms resulting from cervicogenic dizziness typically are associated with injury or cervical spine disease; however, their onset may be sudden 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. The frequency and duration expected for various causes of dizziness. Cervicogenic dizziness typically occurs in episodes lasting minutes to hours. Information 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 interventions that relieve neck pain (modalities, analgesic, and antiinflammatory or muscle relaxant medication). Finally, the therapist should ask the patient for any history of balance difficulties and falls related to the symptoms. A 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 movement or changes in head position with or without neck pain may lead one to think that there is a cervical component. To entertain a diagnosis of cervicogenic dizziness, however, the therapist must be able to correlate the onset and duration of the dizziness symptoms with the neck dysfunction (i.e., dizziness accompanied by neck pain or with head movements). In addition to the complaints about dizziness and neck dysfunction, the therapist should be careful to ask further questions regarding other symptoms that may be perceived by the patient. If symptoms suggest 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

emergent care. The symptoms which are frequently reported after sustaining a whiplash injury require a visit to an otolaryngologist because they are consistent with inner ear pathology. In our opinion, these symptoms do not require urgent attention. The typical secondary symptoms that may be reported at the time of the initial evaluation. We believe that these symptoms are within 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 pathology. 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 trauma; and characteristically lasts less than a minute after a change in position. Cervicogenic dizziness may occur anywhere from days to months or longer after an injury of the head and neck FO with a time course of minutes to hours per episode.

Examination:
Once the history is complete, the therapist can proceed to rule in or out the competing differential diagnoses. Note that the examination procedure presented 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 orthopaedic physical therapy specialist would use for a patient with nonspecific cervical dysfunction. Other, it is an outline of a thorough examination the authors would use to rule in or out a diagnosis of cervicogenic dizziness. The order in which the assessments are performed is at the discretion of the therapist, but an attempt was made to discuss the examination in a logical sequence. The decision-making process that the physical therapist should go through to arrive at a diagnosis of cervicogenic dizziness or other pathology that may present similarly to cervicogenic dizziness. The first step is to determine if the patient with a chief complaint of dizziness or vertigo has neck pain, either at rest, with active neck movement, or with palpation of the neck musculature. This step is important because, by definition, a diagnosis of cervicogenic dizziness is excluded 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 impairment due to a vestibular disorder or may have 2 separate diagnoses, 1 to account for the dizziness and 1 to account for the neck pain. To help establish a diagnosis of cervicogenic dizziness, other vestibular disorders such as benign paroxysmal positional vertigo, Meniere's disease, labyrinthine concussion, and migraine- related vestibulopathy must be ruled out. Although the sensitivity and specificity of vestibular function tests are not very high, 4% the use of vestibular function tests in conjunction with history and clinical examination provides the clinician 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 measure any impairment in the range of motion. Second, the therapist should inquire about any symptoms of pain or dizziness elicited by the active movements. Changes in pain or dizziness can be quantified by comparing the patient's rating of these symptoms with the rating obtained before movement. Third, the active movement can be used to determine if the patient has adequate range of motion for subsequent tests that the therapist may perform, such as the Dix-Hallpike maneuver for benign paroxysmal positional vertigo (BPPV), which requires 30"of cervical extension and 45" of cervical rotation.:" With the patient sitting, the therapist may also perform 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 maneuver. The therapist must make certain that the patient has adequate 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 canal is stimulated in the vertical plane. The Dix-Hallpike maneuver is initiated by having the patient attain the long-sitting position while the therapist rotates the patient's head 45" to one side and brings the patient 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 modified 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 approximately 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 nystagmus is observed with a latency of 5-15 seconds and 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 exercises. A single treatment of the canalith repositioning maneuver has been reported to eliminate symptoms in 72-78% of patients with BPPV, with complete resolution of 91% after 2 treatments. 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 vestibular abnormalities are found by the physician. Considering either diagnosis, the therapist may decide to cotreat with, or refer to, a vestibular rehabilitation physical therapist. Patients with cervicogenic dizziness may complain of poor balance. Balance disorders may be manifested 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 or 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 Confidence Scale as well as functional tests like the Dynamic Gait Index m and the Berg Balance Test. 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 conflicting visual and proprioceptive cues are presented.'

PHYSICAL THERAPY INTERVENTION:

Historically, the intervention for cervicogenic dizziness has included manual therapy (mobilization and manipulation), mechanical traction, physical modalities 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. However, few controlled clinical trials have been performed to determine the effectiveness of these interventions. Three clinical trials that propose intervention for cervicogenic dizziness. These authors report that 73-82% of patients receiving 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 cervical and vestibular symptoms

Reference:
1. Taber's Cyclopedic Medical Dictionary. Philadelphia, Pa: FA Davis; 1997. 2. Alund M, Larsson SE, Ledin T, Odkvist L, Moller C. Dynamic posturography in cervical vertigo. Acta Otolaryngo/ Suppl. 1991; 481:601602. 3. Assessment: posturography. Report of the therapeutics and technology assessment subcommittee of the American academy of Neurology. Neurology. 1993; 43:1261- 1264. 4. Assessment: electronystagmography. Report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology. 1996; 46: 1763-1766. 5. Barre A. Sur un syndrome sympathique cervcial posterieur et sa cause frequente: I'arthrite cervicale. Rev Neurol. 1926; 45:1246-1253. 6. Barrett K, Buxton N, Redmond AD, Jones JM, Boughey A, Ward AB. A comparison of symptoms experienced following minor head injury and acute neck strain (whiplash injury). / Accid Emerg Med. 1995; 12:173-176. 7. Bhansali SA, Honrubia V. Current status of electronystagmography testing. Otolaryngol Head Neck Surg. 1999; l20:419426. 8. Fitz-Ritson D. Assessment of cervicogenic vertigo. / Manipulative Physiol Ther. 1991; 14:193-198. 9. Fitzgerald DC. Persistent dizziness following head trauma and perilymphatic fistula. Arch Phys Med Rehab. 1995; 76:1017-1020. 10. Furman JM, Cass SP. Balance Disorders: A Case-Study Approach. Philadelphia, Pa: FA Davis; 1996 11. Rubin AM, Woolley SM, Dailey VM, Goebel JA. Postural stability following mild head or whiplash injuries. Am / Otol. 1995; 16:216-221. 12. Rubin W. Whiplash with vestibular involvement. Arch Otolaryngol. 1973; 97:85-87.