Why is recent infection a precaution to orthopaedic manual therapy?

Cervical Vertigo, Cervicogenic Dizziness, BPPV, Vestibular Rehabilitation, Cervical Dizziness

Cervical Vertigo, Cervicogenic Dizziness, BPPV, Vestibular Rehabilitation, Cervical Dizziness

In the field of Orthopaedic Manual Therapy, one of the first things we learn are contraindications (relative and absolute) and precautions prior to performing a procedure.  A full list of cautionary measures is beyond this blog post, but one I want to bring to attention is recent infection (particularly throat injection).

Precautions tips for PCBs.png

In conventional clinical reasoning, a recent infection is associated with a risk factor (recent event) for cervical instability but substantially more dangerous of a condition, with fatal consequences, is the arrival of a spontaneous cervical artery dissection.  Frankly speaking, this could be the start of a stroke in process and is an absolute contraindication to physical therapy (or even chiropractic, massage, osteopathic, etc) treatment; but requires medical intervention.

dissection.jpg

We do know there are some risk factors, including trivial trauma (minor and major) and symptomology associated with increased suspicion of a spontaneous cervical artery dissection in process.  One risk factor that continues to arise in the literature but not as confirmatory of a dissection prospect, at least compared to other factors of vascular turbulence, is connective tissue disorders.

I want to send the readers over to a recent article by James Demetrious in the Chiropractic & Manual Therapies Journal (2018).  He examines the thought & reasoning process that Fluoroquinolone antibiotics constitute a risk factor for cervical artery dissections.  I recommend reading the article (it's short AND free) for full details but I want to highlight a quote from the article:

It is plausible that fluoroquinolones may incite connective tissue degradation and play a contributory role in the genesis of cervical artery dissections.....A causal relationship of fluoroquinolone antibiotics to cervical artery dissection is plausible. Fluoroquinolones may indeed be a novel and previously unrecognized cause of cervical artery dissections.

So you may ask, what is the relationship with recent infection??

--->the patient will of course go to a medical physician for potential infection

--->>potentially be prescribed this class of medication (which can cause degradation of connective tissues)

-->> then may or may not have trivial trauma and seek out your consultation and treatment for headache, dizziness, neck pain, etc.

There is definitely more research needed on this topic but I found this to be an intriguing article and confirms more precaution should go through a clinician's mind and reasoning process when a patient has recently had an infection.

In our Cervicogenic Dizziness Course, we go over our Optimal Sequence Algorithm on the first day; which gives you the best of the best in the literature associating risk factors, symptomology & clinical examination procedures to make sure you are confident that the patient in front of you has a mechanical disorder.  We find it is a must when dealing with the intimidating field of dizziness, especially if you aim to address the upper cervical spine.


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

Do THIS before performing Dix-Hallpike Manuever

Cervicogenic Dizziness, Cervical Vertigo, Concussion, Dix-Hallpike Manuever

Cervicogenic Dizziness, Cervical Vertigo, Concussion, Dix-Hallpike Manuever

The Dix-Hallpike Manuever is  considered the gold standard for the diagnosis of posterior semicircular canal Benign Paroxysmal Positional Vertigo (BPPV).  It has decent statistics in its utility in just itself having a sensitivity of 79%, specificity of 75%, LR+ = 3.17 and LR- = 0.28  (Haulker et al 2008) and lends itself very convenient for smooth transition into treatment via the Epley Manuever.

In addition to a thorough patient history, this patient examination piece is crucial in clinical practice guidelines by Bhattacharyya N et al 2008 to assist clinicians in the grey zone of dizziness symptoms.  Agreeing with this work and consensus among clinicians, the practitioner should absolutely differentiate between this benign condition with other, potentially dangerous, reasons for imbalance, vertigo and dizziness.

One of the biggest take-aways I get from our Cervicogenic Dizziness Diagnosis & Treatment weekend course is most "vestibular" clinicians get an "a-ha moment" while learning the Optimal Sequence Algorithm, particularly Appendix C (Cervical Artery Dysfunction)  I say "a-ha" lightly; meaning not to fray upon their current clinical decision making, but the reason WHY we teach ruling out Cervical Artery Dysfunction prior to performing peripheral testing and cervical ROM testing.

We teach a very simple, but effective means to rule out vascular insufficiency (clinical exam) & conditions of spontaneous origin (most likely what will walk in your door) based off of concepts of epidemiology, entire body hemodynamic principles, and triggers to possible cause of a dissection.

This is a huge interest of Harrison's considering the changes in thought-processes and clinical-decision-making of relationship between manual therapy  and stroke over the past decade.  Many myths were put to rest in Harrison's training early in his career that ballooned into more understanding by his Fellowship Mentor, co-author of the Optimal Sequence Algorithm for and ICC partner, Dr. Brent Harper.  Considering Danielle and Harrison come from "different" backgrounds (vestibular and manual training, respectively); we found a missing link in this understanding and present it very clearly in our course.

Openly speaking, causing a stroke from manual therapy is MUCH more prevalent in discussions on this topic compared to performing vestibular rehabilitation of canalith repositioning testing and treating -- even though a spontaneous dissection in process could turn dangerous with even these procedures.  Hence why we our course is called, "Bridging the Gap between Manual and Vestibular Therapies".

Integrative Clinical Concepts. Drs. Harrison & Danielle Vaughan. Cervicogenic Dizziness. Cervical Vertigo.

Integrative Clinical Concepts. Drs. Harrison & Danielle Vaughan. Cervicogenic Dizziness. Cervical Vertigo.

Watch the video attached to this blog of a clip from a short lecture of Harrison speaking at our course describing why it is pertinent to consider vascular origin, specifically spontaneous dissection, with symptoms of dizziness/imbalance/vertigo prior to performing Dix-Hallpike Manuever in patients suspected of BPPV.  Learn this approach to be the most confident in your clinical examination of patients presenting with dizziness, even if your plan is to perform a joint mobilization/manipulation, massage or canalith testing.


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

What if I told you Foam Rollers were not for Rolling

Foam Rolling

Twenty years ago you would hardly have ever seen a foam roller...now they're everywhere.  A search on Amazon for "Foam Roller" produces over 36 pages of results!  A recent news article claims that Tom Brady uses a "vibrating foam roller" to achieve his results.  (Deflating footballs and having Gronk on your team doesn't hurt either. )  But what does the research say about "Foam Rolling" for the release of Trigger Points (TrPs)?

A RCT by Wilke, Vogt, & Banzer (2018) studied the effects of self-foam rolling on Latent TrPs.  The authors took 50 subjects with Latent TrPs in their Gastrocnemius muscles.  I was going to type Gastrocnemi but it just sounds weird...then again, I said "fishes" the other day so I don't know what I'm talking about.  Anyway, the subjects were randomized into 3 groups:

(Wilke, Vogt, & Banzer, 2018, p. 351)

(Wilke, Vogt, & Banzer, 2018, p. 351)

Static compression via Foam Roller for 90 seconds

  1. Dynamic Foam Roller for for 90 seconds

  2. Prone lying with Placebo laser  for 90 seconds

Each subject's TrP was assessed pre and post using a pressure algometer.  So what were the results?  Only one group showed a significant improvement:  The Static compression group.

So was this what you would have expected?  Probably not...but when you consider the dosage over the TrP, the outcomes seem to make sense.  When you have your patient perform a traditional foam rolling with movement, the TrP is actually getting very little stimuli over the actual TrP, while a larger amount of the adjacent area is being stimulated.  Perhaps this is effective in the acute stage of an Active TrP, but not for a Latent, or dormant, TrP.

How should this feel?   

This study instructed subjects to increase the pressure until it feels like a 6-7 on a NPRS.  Another study by Aboodarda et al (2015) also had subjects receive TrP release techniques to a 7/10 on the NPRS.  So it looks like that "strong but comfortable" cue might be appropriate.

Are there any other options for foam rolling?

Well, it turns out that you might also want to consider changing the location.  A study by Cheatham & Kolber (2018) examined the effects of dynamic Foam Rolling on the Quadriceps muscle group.  The results showed the ipsilateral Hamstrings and the contralateral Quadriceps had significantly decreased sensitivity and decreased pain when tested with a pressure algometer.  This aligns with the centralized sensitization model and the overall neurphysiological response elicited with Foam Rolling

Summary

Foam Rolling over the painful or tight area might not be the best option.  An evidence-based approach might be to perform static compression (30-90 seconds) directly over the TrP or to perform Foam Rolling over the antagonist group. 


You can learn more about the screening and treatment for Myofascial Trigger Points through Integrative Clinical Concepts, where the author teaches a full day course.  Aside from the use of Foam Rollers, you will use how to perform emerging release techniques using Static and Dynamic Cupping and other instruments designed for focused stimulation of the restricted areas.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact Dr. Siyufy at courses@iccseminars.com for rates.

ICC:  Advancing Clinical Excellence. Become the clinician your patients are looking for.

References

  1. Aboodarda, S. J., Spence, A. J., & Button, D. C. (2015). Pain pressure threshold of a muscle tender spot increases following local and non-local rolling massage. BMC musculoskeletal disorders, 16(1), 265.

  2. Cheatham, S. W., & Kolber, M. J. (2018). Does Roller Massage With a Foam Roll Change Pressure Pain Threshold of the Ipsilateral Lower Extremity Antagonist and Contralateral Muscle Groups? An Exploratory Study. Journal of sport rehabilitation, 27(2), 165-169.

  3. Weiler, L. (2018). The 1 Workout Tom Brady Swears By Will Make You Rethink EverythingThe Cheat Sheet. Retrieved 30 January 2019, from https://www.cheatsheet.com/health-fitness/the-alternative-workout-tom-brady-swears-by-is-insane.html/

  4. Wilke, J., Vogt, L., & Banzer, W. (2018). Immediate effects of self-myofascial release on latent trigger point sensitivity: a randomized, placebo-controlled trial. Biology of Sport, 35(4).

Stroke following cupping therapy AND a massage? WHAT?!

Cervical Vertigo, Cervicogenic Dizziness, Dizziness, BPPV, Cervical pain

Historically speaking, most practitioners in medicine contribute cervical artery dissection (potentially lead to stroke) to manipulation of the cervical spine--especially from the chiropractic profession.  Several come to my mind including Grant 1987/88, Drueger & Okazaki 1980, Terrett 1987, Hurwitz 1996. This was echoed through the years from emergency medicine physicians in case reports, case series and case control studies but in the last decade, our knowledge on this phenomenon has changed our perspective of the cause.

We now know from the works of many authors, but especially the case-crossover design work of Cassidy in 2008 and reflected again in 2017; that most likely a patient is arriving to your clinic with a stroke in progress.  Briefly speaking, the practitioner must have felt the symptoms were musculoskeletal in nature, but instead, were of vascular nocioception and the headache/dizziness/etc was the symptom that led the individual to seek out help.  Basically, a potentially fatal condition was missed.  For us in the industry who keep up with this data, the trend is leaning towards a more global screening processes including the vascular system to make a more informed decision with positive results, but there are many cases that are still reported, including recently in a Family Practice Journal.

I recently stumbled upon two papers indicating a spontaneous dissection that led a patient to a healthcare provider---in these cases the treatment approach was not manipulation, but cupping and massage.

I can provide full texts to those who wish to read, but here is synopsis:

Choi et al 2016

We report an extremely rare case of spontaneous extracranial VA dissection presenting with posterior neck hematoma aggravated after cupping therapy.

"We presume that when spontaneous extracranial VAD occurred, his neck pain began and the cupping therapy caused a VA rupture and posterior neck hematoma with a pseudoaneurysm."

Dutta et al 2018

We present an unusual case of vertebral artery dissection in a 30-year-old male patient following an episode of neck massage....The current case demonstrates the hazards associated with neck massage and the potential for good outcomes in these patients if timely intervention is provided.

For those of you who treat headaches, neck pain and dizziness; albeit very rare, you should always keep in mind potential cervical artery dysfunction.  It could arise spontaneously or after a trauma, even trivial.  Although we are still working in a diagnosis and area of uncertainty, I would suggest these two reports correlate with our trend that the actual procedure doesn't cause the stroke---but instead, the acute arterial event was occurring spontaneously which led to a patient coming to you for help.

In the Optimal Sequence Algorithm of our Cervicogenic Dizziness Course, this is a hot topic and one that I take very seriously.  Alongside my fellowship mentor, Dr. Brent Harper, we have designed what we both find to be the most up-to-date and sound reasoning to rule out spontaneous and mechanical vascular event.  We strive to improve the order of your examination definitely makes a difference --- which is one of the major flaws behind the vertebral-basilar insufficiency (VBI) test.

Even though I find our approach is quite sound, I want to end this post with the conclusion from Choi et al 2016 as it is a solid statement and a major take-home point:

The clinical diagnosis of VAD is not easy with acute-onset neck pain, especially young patients with no evidence of cervical trauma and disease. With undiagnosed VAD, traditional remedies such as cupping and chiropractic therapy to reduce pain can aggravate spontaneous dissection and worsen symptoms.....Early diagnosis of VAD could prevent symptom aggravation and permanent neurologic deficit.


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the author and his wife, a Vestibular Specialist, teach a 2-day course.  Pertinent to this blog post, the first day provides the most up-to-date evidence review from multiple disciplines to diagnose through the “Optimal Sequence Algorithm” to assist in ruling out disorders and ruling in cervical spine, including determining if single or double entity exists.  

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for prices and discounts.

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Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

How common is Cervicogenic Dizziness?

prevalence-02.png

When considering dizziness of cervical origin, it is well accepted in clinical practice to follow the rule of "diagnosis of exclusion".  This means that you can suspect, but not confirm, dizziness or vertigo from the neck unless you rule out other competing diagnoses.

It is thrown around from ones who try to invalidate the condition that up to 90% of cases can have a convincing alternative diagnosis.  Additionally, Cervicogenic Dizziness can affect populations across the lifespan with traumatic and even non-traumatic origin. Therefore, the prevalence of Cervicogenic Dizziness can be challenging to truly calculate.

However, we can reach out to the literature to provide some input on how frequent patients have Cervicogenic Dizziness.  We provide a synopsis for you below to help with prevalence rates for these subcategories.

Elderly / Geriatrics

A classic study cited in most often comes from Colledge et al in 1996 in BMJ.  This is a community based study looking at causes of dizziness in elderly patients in primary care practice.  The investigators found that 30% of total patients had dizziness symptoms and contributed 66% of those cases to cervical spondylosis (arthritis).  Two-thirds of the patients with dizziness coming from the neck is a significant proportion!

A more recent study by Sho Takahashi in 2018 retrospectively examined the cause of general dizziness in an outpatient setting.  Out of the 1000 patients, 899 (90%) were found to have cervicogenic general dizziness.  The authors contribute cervical spinal canal stenosis as the culprit in the group with average age of 62 years old.  Wow, 9 out of 10 patients were found to have dizziness coming from the neck!

So yes, the geriatric population, even though with higher proportion of competing diagnoses including peripheral, cardiovascular, and psychological causes; have a high prevalence of Cervicogenic Dizziness.  For therapists out there who are in vestibular rehab / neuro rehab and even home health, this is something to consider!

We can't forget the data from the concussion and whiplash literature.  Here are some other robust numbers for you:

Concussion

You can't disagree that assessment of the cervical spine in post-concussion management and treatment is important.  However, the prevalence of cervical spine pathology in concussed patients is unknown. Many authors express interest and promote the manual assessment of the cervical structures, including Leddy et al 2015, Gergen 2015, Scorza et al 2012Ellis et al 2015Craton et al 2017Cheever K et al 2016, Matsuszak et al 2016, Morin et al 2016Marshall et al 2015, Elkin et al 2016Putukian 2017, Lundblad 2017  Growbaski et al 2017, and Kosoy/Feinstein 2018.

Also, you can also go back to 1956 to read an article by Seletz in Calif Med Journal entitled, "Craniocerebral Injuries" (a free paper).  So, yes, this concept is not new.

There will be tons more coming out in the concussion literature over the next few years to aid in prevalence rates themselves, but here are studies we present to our classes:

Kennedy et al 2017, in a retrospective chart review study, found that 32 of 45 (69.5%) of patients with persistent post-concussion symptoms, were found to have cervicogenic component.  The authors highlight the value of physiotherapy assessment and treatment of the cervical spine following a concussive injury.

Reneker et al 2015, in a cross-sectional study of athletes after a concussion, found 82.9% had cervical involvement and 26.8% presented with Cervicogenic Dizziness.

A classic, Scheider et al 2014, in a randomized controlled trial to treat concussion in adolescents, found 100% of patients in both treatment AND control group had cervical spine findings.  Moreover, 93.33% in treatment group had neck pain while 87.5% in control group had neck pain. Additionally, 86.33% had dizziness in treatment group and 82.75% had dizziness in control group.

Marshall et al 2015, albeit a review paper BUT also a case series, discusses the role of many theories causing post-concussive syndrome.   Pertinent to this post, the authors give credence to "a very treatable" cause of it---the cervical spine.

Jensen et al 1990 found that 18 out of 19 (94.7%) patients with persistent post-concussive syndrome had upper cervical spine restrictions when compared to an uninjured control group. Their work concludes that it supports the hypothesis of a cervical mechanism causing post-traumatic headache and suggests that post-traumatic dizziness, visual disturbances and ear symptoms could be part of a cervical syndrome.

Treleaven et al 1994 demonstrated in 12 patients with post-concussive had upper cervical spine dysfunction compared to a normal control group.

Going back even further, Mager et al 1989, noted a block of the upper cervical spine and of the cervicothoracic area was proved in 83.53% of patients who were hospitalized upon a head injury.

Whiplash

The literature on this is somewhat older but still very pertinent, stands true to today, and actually we have more data from multiple sources.  I always say about half of patients who have had whiplash-associated disorder experience dizziness and/or imbalance. To name a few, I recommend reading the works of Diane Wrisley 2000, Oostesteveld et al 1991, Skovron 1998, Humphreys & Peterson 2013. 

Non-Traumatic Cervicogenic Dizziness

For those who are not treating the elderly and not dealing with trauma, the numbers are not nearly as hefty.  I always mention to my students that the prevalence in this realm is ~10%.  Even though the patient age and criteria within these studies vary, I lump this under non-traumatic Cervicogenic Dizziness. This is where I get my data:

Ardic et al 2006, in a retrospective chart review, noted dizziness of cervical origin at 7.5%.

Luscher et al 2014, in a prospective, observational, multi-center study, noted dizziness of cervical origin at 6.4%.

Reid et al 2015, in a randomized-controlled trial, had 8.5% of participants fulfill the inclusion and exclusion criteria as having Cervicogenic Dizziness.

From the outside looking in, the literature is all over the place with our prevalence numbers!  This is what makes the condition challenging and exciting to treat and help others.  You can consider Cervicogenic Dizziness as a single entity, double entity and even traumatic vs non-traumatic origin. Therefore, the prevalence of Cervicogenic Dizziness can be challenging to truly calculate.  I hope this information helps you make a better decision in the office.


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 1st day includes the “Optimal Sequence Algorithm”, a multi-faceted physiotherapist approach to the assessment of Cervicogenic Dizziness, which includes the appropriate ruling-out process and cervical examination of the articular and non-articular systems. Also pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

Concussion: Purely a brain injury or are there more pragmatic treatments?

Cervicogenic Dizziness, Post-Concussive Syndrome, Cervical Vertigo, Concussion, Dizziness

 

Concussion has been a hot topic in the last few years and continues to grow in awareness, diagnostic and treatment options in the field of medicine.  Rehabilitation professionals, such as physical therapists, play a vital role in recovery from this injury and can be argued to be the best healthcare provider to aid in a progressive, graded exposure to return to sport/play.  Treating patients recovering from this injury can be challenging but our field offers us the training and ability to address the multiple dimensions of symptoms; including the oculomotor, vestibular, cervical and central impairments.

Even though concussion can be considered physiologically a "brain injury", there is a plethora of data correlating the mechanism of injury and impulsive forces to whiplash mechanism, such as seen in a car wreck (Elkin et al 2016, Alexander 2003, Hynes & Dickey 2006, Morin 2016).  So not only could impulsive forces in concussion involve the head, but the neck as well (Marshall 2015, Kennedy 2017).  This is not a new subject per say, but with the continued expression of "brain injury" and "central condition"; I want to express to my colleagues that symptoms of headache and dizziness could be generators of nocioception and/or alterered proprioception.  There have been some authors to go as far as suggesting concussion should be appropriately called the monikor craniocervical shaky syndrome (CCSS).

brain.png

Instead of simply allowing the brain injury diagnosis sticker dampen the prognosis to allow healing to occur, it is recommended to consider the cervical spine a potential reason/cause for post-concussion persistent symptoms.  Considering dizziness after sport-related concussion is common and reported to be in 43-81% of cases (Alslaheen et al 2010, Duhaime et al 2012, Lau et al 2011), it is highly recommended to get the formal assessment, evidence and treatment for these patients.

Let's move on together to aid in finding potential, pragmatic and VERY treatable region of the body.  It can be challenging to find which system is of particular importance in the driver of post-concussive symptoms, but if you think it is the cervical spine, we have the answers for you.  


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 1st day includes the “Optimal Sequence Algorithm", a multi-faceted physiotherapist diagnostic approach of Cervicogenic Dizziness, which includes ruling out central and peripheral disorders to rule in the cervical spine as driver of proprioceptive dysfunction.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Is Osteopathic Treatment effective on Cervicogenic Dizziness?

Cervical Vertigo, Cervicogenic Dizziness, Cervicogenic Dizziness Course

While answering the question, "Is Osteopathic Treatment effective on Cervicogenic Dizziness", I must preface to say I am not an osteopathic physician and do not practice in that theoretical construct.  However, for those readers who understand the mechanisms of manual therapy and history behind the field of Physical Therapy and Osteopathic medicine; I am sure you can appreciate the correlation of Osteopathic medicine and subset of Manual Therapy within the larger scope of practice in Physical Therapy.  Here is a synopsis if you haven't delved into the history.  Understanding this correlation will allow the clinician to delve deeper into the literature of other professions in order to have a broader consideration of the effects of manual therapies on individuals suffering from Cervicogenic Dizziness and ultimately give your patients the most comprehensive treatment.

While inquiring PubMed for literature support, unfortunately the terminology of Cervicogenic Dizziness comes up empty.  Why?  Well, read a previous post for that.  Nonetheless, Cervical Vertigo brings me information from Hulse et al in 1975.  As expected, the thought process realms from disturbances of the upper cervical spine and the authors recommend manipulation as treatment of choice.

As the years go by, it is difficult to find literary works specifically for the benefit of Osteopathic treatment for Cervicogenic Dizziness.  However, we do have a some information provided by:

  • A case report by Kennedy in 2002

  • A case report by Shaffer in 2005

  • A case report by Fraix in 2009.

  • A case series by Berkowitz in 2009.

  • A case report by McCallister et al 2016 - of note, this was on a patient with severe TBI

Since these are in the lower levels of evidence, the main chunk of justification doesn't start until when we delve into Fraix's work in 2010.  A pilot study, here is Fraix's conclusion

This study showed that OMT is generally well tolerated in patients with vertigo. It also demonstrated that it is feasible to recruit a population of patients with vertigo who can complete a course of OMT and collect data by using the DHI. A randomized control trial that examines the efficacy of OMT in patients with vertigo is warranted, given that OMT may be a reasonable treatment for vertigo and the functional impairment associated with it.

Of course this study has limitations, but I do like how it uses the Dizziness Handicap Inventory (DHI) as a functional outcome measure to show effectiveness of the intervention with a validated and reliable outcome measure.  See results in Figure 1 from the article below:

Screen Shot 2018-05-12 at 1.38.43 PM.png

As far as I know, a follow-up RCT designed to compare Osteopathic Treatment to Vestibular Rehabilitation never made it to publication.  However, we do have some other evidence of the effects of osteopathic treatment in the last few years.

In 2013, Fraix and colleagues in a prospective clinical cohort study evaluated the effect of osteopathic manipulative treatment (OMT) for spinal somatic dysfunction in patients with dizziness lasting longer than 3 months.  Here is their conclusion:

Osteopathic manipulative treatment for spinal somatic dysfunction improved balance in patients with dizziness lasting at least 3 months.

Screen Shot 2018-05-12 at 1.53.32 PM.png

 

In 2017, Papa and colleagues in a randomized control trial examined a group of 31 individuals with BPPV and again used DHI as outcome measure.  Here is their conclusion:

These findings suggest that OMT could be a useful approach to reduce imbalance symptoms and to improve the quality of life in patients suffering from dizziness

Screen Shot 2018-05-12 at 1.55.02 PM.png

In conclusion, the evidence is slowly, but starting to mount to give more credence to Osteopathic Treatment for Cervicogenic Dizziness.  I do not hesitantly justify this as simply another means of evidence denoting the benefit of manual therapy, which can be provided by trained physical therapists, for the treatment of Cervicogenic Dizziness / Cervical Vertigo.

The justification for our services and approaches are continuing to mount, for the sake of the patient, our referral sources, for us personally and for the 3rd party payers.  Anyone who has taken my courses knows evidence is a top priority and you will get the information you need to not only learn how to diagnose and treat Cervicogenic Dizziness, but the paper trail that puts more substance into our practice. 


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Would you harm a patient with manual therapy already diagnosed with concussion?

Cervicogenic Dizziness, Cervical Vertigo, Cervicogenic Dizziness Courses, BPPV, Cervical Spine, Dizziness

The title of this blog is a loaded question, but generally speaking it entails the risk : benefit ratio and adverse events of performing manual therapy on a patient who has suffered a concussion.  In particular, we are speaking of someone who is suffering from post-concussive symptoms after mild traumatic brain injury (mTBI).  In this post, we will use mTBI synonymously with post-concussion symptoms. This patient is already in your office, you have determined some type of musculoskeletal generator for symptoms, most likely neck pain, dizziness and/or headache; so you proceed with what you have in your tool box.

Cervical spine involvement in mTBI is gaining more traction over the years. There have been countless case reports and case studies on the benefit of manual therapy for mTBI (to name a few--Gurnseley 2016, Burns 2015, Weltzer 2017).  In fact, Brolinson recommends using manual therapies alongside neuromotor/sensorimotor training for more effective  mTBI recovery than rest and exercises.  Also, we can't forget the all important Schneider study from 2014 that found a significant number of athletes returned to sport in manual / vestibular group compared to control group.

Most recently, Quatman-Yates in 2016 found the following conclusion:

The results of this systematic review indicate that several physical rehabilitation options with minimal risk for negative outcomes are available for treating patients experiencing persistent post-mTBI symptoms. These options include: vestibular, manual, and progressive exercise interventions.

In general, the literature does guide us that manual therapies can be a safe and effective intervention to the cervical spine for mTBI.  In fact, if you break down adverse events in Cervicogenic Dizziness / Cervical Vertigo, you will not find the literature shying away from manual therapy either.  Even though no study has been conducted directly examining adverse events, it can be noted that the largest randomized control trial and long term outcomes to date by Reid and colleagues specifically state no adverse events in the group of eighty-six participants receiving manual therapy.

However, there is one study I want to bring to light.  It is from Dr. Greenman and his colleague, Dr. McPartland back in 1995 entitled, "Cranial findings and iatrogenesis from craniosacral manipulation in patients with traumatic brain injury".  For those who do not know, Greenman was well known at Michigan State in Osteopathic Medicine and well cited in books and journals.  Even though the practice and treatment of craniosacral manipulation is beyond this blog and post, it is worth noting the findings of this brief review below:

Out of 55 cases, the authors describe 3 cases of adverse events of craniosacral therapy in patients with mTBI, including 2 requiring hospitalization.  They noted a 5% incidence rate and quoted the following, "craniosacral manipulation in a traumatic brain-injured patient can be useful and effective, but is not without risk".

This number may not mean much to you---but we all hope as clinicians it is 0%---but it all depending on how you define iatrogenesis.  Nevertheless, I suggest you compare this number to Carnes' 2010 study noting incidence estimate of proportions for minor or moderate transient adverse events after manual therapy was approximately 41% (CI 95% 17-68%) in the cohort studies and 22% (CI 95% 11.1-36.2%) in the RCTs; for major adverse events approximately 0.13%.

However, Sabel and Patini in 2018 in a pilot study examined safety of Osteopathic Manipulative Medicine in PostConcussion Symptom Management and elicited the following conclusion:

Osteopathic cranial manipulative medicine was considered a safe adjunctive treatment option to improve concussion-related symptoms and recovery.

In conclusion, I say there are minor adverse events to any intervention but we definitely want to have a treatment approach that minimizes risk while add benefit.  The type of technique, approach and handling skills can all be combined to making this formula turn out best for you and the patient.  In our Cervicogenic Dizziness Course, we teach a variety of techniques that add on what you already know and propel it towards maximal comfort and relief.  Come check us out near you.


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

How common is Cervicogenic Dizziness in Concussion?

Concussion

Over 80% of concussions have been observed to recover within 7-10 days, but ~20% of sports-related concussions can take longer than this period of time to resolve.  Predictors and factors associated with a protracted recovery and reasons for post-concussive symptoms can be of many reasons but for the purpose of this post, we will delve into the cervical spine.

You can't disagree that assessment of the cervical spine in post-concussion management and treatment is important.  However, the prevalence of cervical spine pathology in concussed patients is unknown.  Many authors express interest and promote the manual assessment of the cervical structures.  I recommend delving into the research by these authors: Leddy et al 2015, Gergen 2015, Scorza et al 2012Ellis et al 2015Craton et al 2017Cheever K et al 2016, Matsuszak et al 2016, Morin et al 2016Marshall et al 2015, Elkin et al 2016Putukian 2017, Lundblad 2017  , Schneider et al 2018 and Kosoy/Feinstein 2018.

Even though concussion research and awareness has spiked in the last few years, you can also go back to 1956 to read an article by Seletz in Calif Med Journal entitled, "Craniocerebral Injuries" (a free paper).  So, yes, this concept is not new.

However, if you're looking for a newer model to adopt, I recommend reading Mark Lundblad's work in 2017 paper in Int J Sport Phys Ther entitled, "A Conceptual Model for Physical Therapists Treating Athletes with Protracted Recovery Following a Concussion".  He does mention that the first component to address (prior to neuromuscular control and strengthening) is cervical mobility and C1-2 should be of particular importance.

In regards to Cervicogenic Dizziness following Concussion, we don't know the prevalence rates of Dizziness itself from the Cervical Spine but we do know most common symptoms are headaches, dizziness, fatigue and other range of cognitive deficits.  More research and scientific inquiry is on headaches vs dizziness from the cervical spine, but we can all agree even though we are looking at a proprioceptive vs nocioceptive alteration in input, that some of the actual structures at fault can be similar.

There will be tons more coming out in the concussion literature over the next few years to aid in prevalence rates themselves, but here are studies we present to our classes:

ask-smithsonian-05272015-concussion-still-2.jpg

 

Just recently, Ellis et al 2018, in a retrospective cohort study, actually looked at Cervical Spine Dysfunction in Pediatric Sports Related Concussion.  Out of the 246 patients included in the study, 80 of them (32.5%) met the criteria for cervical spine dysfunction.  The authors conclude that cervical spine dysfunction can be a risk factor for delayed clinical recovery.

Kennedy et al 2017, in a retrospective chart review study, found that 32 of 45 (69.5%) of patients with persistent post-concussion symptoms, were found to have cervicogenic component.  The authors highlight the value of physiotherapy assessment and treatment of the cervical spine following a concussive injury.

Reneker et al 2015, in a cross-sectional study of athletes after a concussion, found 82.9% had cervical involvement and 26.8% presented with Cervicogenic Dizziness.

A classic, Scheider et al 2014, in a randomized controlled trial to treat concussion in adolescents, found 100% of patients in both treatment AND control group had cervical spine findings.  Moreover, 93.33% in treatment group had neck pain while 87.5% in control group had neck pain. Additionally, 86.33% had dizziness in treatment group and 82.75% had dizziness in control group.

Marshall et al 2015, albeit a review paper BUT also a case series, discusses the role of many theories causing post-concussive syndrome.   Pertinent to this post, the authors give credence to "a very treatable" cause of it---the cervical spine.  All of the cases demonstrate several different types of manual therapies to the cervical spine to aid in improving symptoms.

Growbaski et al 2017, in a retrospective cohort study, expressed that over 75% of the patients experienced symptoms consistent with peripheral vestibular disorder or cervicothoracic dysfunction, either in isolation or in various combinations, in their multimodal, impairment-based PT approach to treating post-concussion syndrome.

Browne GJ 2006 found that in the retrospective descriptive case series study of 125 children who injured their cervical spine while playing rugby football, 98% of them had neck pain (of course if injured neck), but out of these 125 children, 23% had a concussion.

Jensen et al 1990 found that 18 out of 19 (94.7%) patients with persistent post-concussive syndrome had upper cervical spine restrictions when compared to an uninjured control group. Their work concludes that it supports the hypothesis of a cervical mechanism causing post-traumatic headache and suggests that post-traumatic dizziness, visual disturbances and ear symptoms could be part of a cervical syndrome.

Treleaven et al 1994 demonstrated in 12 patients with post-concussive had upper cervical spine dysfunction compared to a normal control group.  This study examined headaches.

Going back even further, Mager et al 1989, noted a block of the upper cervical spine and of the cervicothoracic area was proved in 83.53% of patients who were hospitalized upon a head injury.

How common is Cervicogenic Dizziness after Concussion?

cgd.png

The values above are just several examples of prevalence rates of cervical component in head injury from concussion. Unfortunately, I don't have specific values for you as most studies lump Cervical Dysfunction as criteria to treat musculoskeletal symptoms or Dizziness symptoms in peripheral disorders but don't differentiate between the two. 

However, we can at least appreciate that 1/4 of patients with concussion have Cervicogenic Dizziness following results of Jennifer Reneker's work in 2015.  What do you see in the clinic?  Do you think the percentage is larger than what is presented in the research? 

I hope this provides you some phenomenal information to take back to the clinic!  Overall, we can definitely rule out the cervical spine via a few tests and if you can't rule it out, we do have some specific tests to aid in ruling in the condition.

Also---keep in mind, this data doesn't include the plethora of information from the whiplash-associated disorder diagnoses either!  You will see a future post on this data so sign up for email alerts! If you're seeing head injury patients, post-concussion syndrome, and even whiplash and do not address the cervical spine, I hope this post gives you credence to examine it further.

You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 1st day includes the “Optimal Sequence Algorithm”, a multi-faceted physiotherapist approach to the assessment of Cervicogenic Dizziness, which includes the appropriate ruling-out process and cervical examination of the articular and non-articular systems. Also pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

 


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 1st day includes the “Optimal Sequence Algorithm”, a multi-faceted physiotherapist approach to the assessment of Cervicogenic Dizziness, which includes the appropriate ruling-out process and cervical examination of the articular and non-articular systems. Also pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

5 reasons to take our Cervicogenic Dizziness Course

1. Cervicogenic Dizziness is more prevalent than you think

Cervicogenic Dizziness, Cervical Vertigo, BPPV, Neck pain and Dizziness, Sensorimotor Training

Nowadays, most people think of Cervicogenic Dizziness of arising after a concussion.  We can't forget the higher percentage of patients suffering from Cervicogenic Dizziness after a whiplash, other mild traumatic brain injuries and patients with cervical arthritis.  If you see patients with neck pain, then they could have Cervicogenic Dizziness and you need this class!  Oh, and don't forget the double entity of Cervicogenic Dizziness with your patients with BPPV.  Could this be the reason their symptoms come back??

2. Treatment for Cervicogenic Dizziness is MUCH more than just Mulligan Techniques

Cervicogenic Dizziness, Cervical Vertigo, BPPV, Neck pain and Dizziness, Sensorimotor Training

You can't disregard the highest level of evidence in randomized controlled trials by Susan Reid and her colleagues in the successful treatment of Cervicogenic Dizziness.  We definitely go over the powerful effects of this approach! However, if you read outside the physical therapy literature, you will find a copious amount of success in the treatment of Cervicogenic Dizziness from the Chiropractic works, Acupuncture Works,  ENTs, Audiologists,  and even from Medical Physicians.  With over 600 referenced articles in our course, we cover it all to give you the best of the best in all around treatments for Cervicogenic Dizziness.  If you want to know how to treat the upper cervical spine joints and fascial points manually and then with follow up exercises, all in one class, this is perfect for you!

3. You will be taught by both a Vestibular Specialist and a Manual Specialist

Cervicogenic Dizziness, Cervical Vertigo, BPPV, Neck pain and Dizziness, Sensorimotor Training

When my wife and I decided to put together our course, it was both exciting to bring our "two fields" together but challenging!  As a manual trained therapist, I have a different "lens" than she does, and as a vestibular therapist, she has a different "lens" than I do.  This is what makes our course both unique and personable!  You will not find this combination to bring you the best of the best in treatment of Cervicogenic Dizziness anywhere else.

4. Sensorimotor Training is the future of Physical Therapy

Cervicogenic Dizziness, Cervical Vertigo, BPPV, Neck pain and Dizziness, Sensorimotor Training

For anyone keeping up with trends and advanced in literary works, you will notice that much more data and evidence is arising for the benefit of Sensorimotor Training.  Considering the cause of Cervicogenic Dizziness is due to disruption in multiple systems with ultimate failure in the proprioceptive system, you cannot fully treat this condition without Sensorimotor Training.  Not only do we teach this approach after our manual therapies, but we have specific approaches and exercise programs for your patients suffering from Cervicogenic Dizziness.

5. Cervicogenic Dizziness is brushed on in your Vestibular and Manual Courses

Cervicogenic Dizziness, Cervical Vertigo, BPPV, Neck pain and Dizziness

When my wife and I came together to write our > 300 page manuscript for our Cervicogenic Dizziness Course, we ultimately realized that Cervicogenic Dizziness was just brushed at the surface in both of our advanced training.  Therefore, we brought together a course that is perfect for a "vestibular" OR "manual" therapist that has the most detail and up to date information for any clinician.  If you "think" your patient has this condition or seeing a trend, you ultimately need to take the course to treat it most effectively.  Be the expert in both at your clinic!

$100 off 2018 courses ends July 6 for Richmond, VA and July 10 for Hawaii!  Sign up now to save money!


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 1st day includes the “Optimal Sequence Algorithm”, a multi-faceted physiotherapist approach to the assessment of Cervicogenic Dizziness, which includes the appropriate ruling-out process and cervical examination of the articular and non-articular systems. Also pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Cervical ROM Asymmetry in Cervicogenic Dizziness

Flexion Rotation Test, C1-2, Cervicogenic Dizziness, Cervical Vertigo

Cervicogenic Dizziness / Cervical Vertigo

As much as I do not like the word asymmetrical in regards to musculoskeletal care for many reasons, we cannot neglect its role in the history of our profession.  Historically, clinicians would eye-ball range of motion and even use palpation to determine deficits side to side with resultant definitions and/or descriptions to the patient that could be the reason for his/her symptoms.  We all know the reliability and validity of these measures have their own downfalls and with advanced scientific scrutiny of our own tests, these methods are dying out.  However, there is one test that has been shown to be valid, reliable and useful in the differential diagnosis of certain conditions.  This test is the Flexion Rotation Test.

Flexion Rotation Test, C1-2, Cervical Vertigo, Cervicogenic Dizziness

Back in 2004, Hall & Robinson were the first (to my knowledge) to study and cite the Flexion Rotation test in a comparative measurement study for Cervicogenic Headache.  This test has stood the test of time and continues to be highly valuable in studies examining the upper cervical spine.  I wrote a 3 part series on it over 8 years ago (Part 1, Part 2, Part 3) and still use it consistently to this day!  Even though the Flexion Rotation Test has been validated in Cervicogenic Headache and continues to be a major player in a battery of examination tools for Musculosketal dysfunction in Migraines, its role in diagnosing Cervicogenic Dizziness as a valid measure is lacking.

The purpose of the Flexion Rotation Test is to measure the mobility at the atlanto-axial (AA) joint, which of course is in the upper cervical spine complex.  It encompasses 50% of the rotation of the cervical spine and a major musculotendinous attachment point. Even though the neurophysiology of nocioception from the upper cervical spine to produce Cervicogenic Headaches is more common, there is a plethora of information on the proprioceptive neurophysiology from the upper cervical spine to produce Cervicogenic Dizziness.

Most recently, Quek et al 2013 sought out whether the upper cervical spine rotation ROM asymmetry is associated with postural stability.  The authors found Cervical Flexion-rotation ROM asymmetry group had greater postural sway and from a statistical analysis viewpoint, the study emphasizes the need to consider Cervical Flexion-rotation-ROM asymmetry as an independent predictor of standing balance, over and above the influence of neck pain intensity.  This is a powerful statement and considering in we are dealing with altered orientation, dysequilibrum, and unsteadiness in Cervicogenic Dizziness; we can't ignore this striking finding on correlating postural stability with AA mobility.

However, for MORE diagnostic power in evidence-based practice, we need MORE than just conjecture from basic science and relating range of motion to postural stability.

The clinical reasoning process to diagnose Cervicogenic Dizziness takes the basic science, add a screening process via the Optimal Sequence Algorithm , obtain the appropriate subjective and other objective testing measures---including the Flexion Rotation Test---and BAM...make the clinical diagnosis...doesn't this count as validation?

Honestly this is what we currently have in regards to using the Flexion Rotation Test for Cervicogenic Dizziness.  We don't have a true validation study as we do with Cervicogenic Headaches, but we do have some more oomph from the ivory towers to help make our decision.  To assist with our argument, we have case reports (Gargano et al 2012), case series (Escaloni et al 2018Jung et al 2017) Delphi Study (Reneker et al 2015), case control study (Morgan CD et al 2015), reviews (Cheever K et al 2016) and position statement (Harmon et al 2013).  These literary works all discuss and/or use the Flexion Rotation Test for Cervicogenic Dizziness.

One thing I want to point across is the lack of validation of a test does not mean you can't make inferences.  With basic science input from C0-3 and several studies demonstrating the abnormal findings of C1-2 via the Flexion Rotation Test relating to patients with dizziness, we can't ignore this excellent test.  Use it but use it with strong clinical reasoning for your patients with dizziness to determine how much could be musculoskeletal in nature.


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 1st day includes the “Optimal Sequence Algorithm”, a multi-faceted physiotherapist approach to the assessment of Cervicogenic Dizziness, which includes the appropriate ruling-out process and cervical examination of the articular and non-articular systems. 

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

c1-2.png

Sensorimotor Impairment Treatment in Concussion and Whiplash Patients

Cervicogenic Dizziness, Cervical Vertigo, Dizziness Cervical Spine, Physiotherapy, Physical Therapy, Concussion, mTBI, Whiplash, Harrison Vaughan, Danielle Vaughan

Cervicogenic Dizziness / Cervical Vertigo

It is now well know the correlation between symptoms and physiological effects that are sustained following patients who suffered from concussion and whiplash.  Even though there are still apparent differences clinically, we can now feel comfortable to lump these two conditions together.  It may surprise some readers --- but in this article -- and most likely in the medical literature in the future -- we will collectively call the injury a mild traumatic brain injury (mTBI).  

Galea and colleagues just came out with a Meta-Analysis in 2018 to determine whether persistence of sensorimotor or physiological impairment exists between 4 weeks to 6 months post injury.  More than likely the clinicians reading this article will see a patient suffering from symptoms > 10 days following the injury for definition  of post-mTBI symptoms, but could be between 4-12 weeks so your patient fits in nicely in the objective.  More than likely we are seeing them for dizziness, headaches, neck pain, difficulty concentrating, etc.  

For those interested in reading the entire analysis, feel free to reach out to me for article, but for blog purposes; here is the conclusion:

Findings demonstrate that persistence of sensorimotor and physiological changes beyond expected recovery times following subacute mTBI in an adult population is possible. These findings have implications for post-injury assessment and management.

Big points I want to you to get out of this conclusion. 

Firstly, the "is possible" statement from first glance isn't conclusive at all---but for a meta-analysis---I will take it! 

Secondly, and reason we aim for to read and perform research, is this statement, "these findings have implications for post-injury assessment and management".

The assessment and management of this very complicated and the challenging condition of mTBI is beyond what can be written in words.  In fact, my wife and I teach 16 HOURS worth of updated and modern content to make you more confident in treating someone suffering from mTBI who has Cervicogenic Dizziness / Cervical Vertigo.  This doesn't even include the science and application of treating the other symptoms!

We do know that the presentation of a patient who could have Cervicogenic Dizziness / Cervical Vertigo is much more than someone who has suffered a recent mTBI; but this Meta-Analysis has huge implications for our instructional content and approach.  In fact, a large percentage of our course is dedicated to the assessment and management of Sensorimotor changes.  

Doesn't this last bolded statement correlate nicely with the latest highest-level evidence from Galea et al that was quoted above?

If you're looking to maximize your patient's outcomes---check out a course near you!


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Is it Cervical Vertigo or Cervicogenic Dizziness? A Clarification

Cervicogenic Dizziness, Cervical Vertigo, Dizziness Cervical Spine, Physiotherapy, Physical Therapy, Harrison Vaughan, Danielle Vaughan

Cervicogenic Dizziness / Cervical Vertigo

Any clinician working in the neuromusculoskeletal field knows we have a big problem in describing conditions that we diagnosis and treat.  You get 10 PTs to examine a patient and you may get 10 different explanations.  A colleague's work has even just eliminated all abbreviations across all of their clinics as we can't get that right either!

Additionally, there has always been the multi-term description of a "joint problem"---somatic lesion, derangement, dysfunction, hypo mobile joint, hyper mobile joint, etc etc.  The trend is even getting less specific with conditions that have historically carried a diagnostic term.  Subacromial impingement is now being called anterior shoulder pain and patellofemoral pain syndrome is now being called anterior knee pain.

One of the main reasons for this discrepancy is that we have a challenging time correlating the actual source of nocioception from a clinical exam, and can be even less accurate with imaging exam for the above two conditions.  Even more, the purpose of a diagnosis is to lead to a sound treatment plan, but this depends on multiple variables.  Providing a clarification for our findings is challenging.

In the dizziness world, the subjective and variable explanation of symptoms makes the clarification of terminology even more challenging.  

The current medical definitions of vertigo, dizziness, and imbalance are based on the recommendations made by the classification committee of the International Bárány Society for Neuro-Otology.

Vertigo is the sensation of self-motion when no self-motion is occurring; dizziness is the sensation of disturbed or impaired spatial orientation without a false or distorted sense of motion; and imbalance or unsteadiness is the feeling of being unstable while sitting, standing, or walking without a particular directional preference.

Additionally, dizziness may be described as feeling dizzy, lightheaded, giddy, faint, spacey, off-balance, rocky, spinning, or swaying (Newman-Toker DE & Edlow JA 2015).  Aren't these descriptions all over the board?!

The definition of Cervicogenic Dizziness / Cervical Vertigo is even more muddy.  Here is a sample of dizziness descriptions from leading authors, alongside correlating them with neck positions/movements.  This is a small collection from my 300 page book (provided with course registration):

Non-rotary dizziness, imbalance, unsteadiness (Reid 2008/2012/2014/2015)

Vague sense of impaired orientation or disequilibrium (Al Saif 2011)

Non-specific sensation of altered orientation in space and disequilibrium (Furman/Cass 1996, Wrisley 2000)

For the most part, dizziness means different things to different people.

One thing I want to point out above is that the description and definition of Cervicogenic Dizziness does not involve vertigo---which is definied as a "sense of spinning, surroundings seem to whirl such as feeling that you are dizzily turning about you".  This is typically associated with BPPV (hence the "V").

In the literature on this topic, you may find  the phrases, "Cervical Vertigo (CV) , Cervicogenic Dizziness,  or Cervicogenic Vertigo" as you search across multiple discipline journals.  Considering vertigo is not a typical description or definition associated with dizziness associated with the cervical spine, I suggest abandoning the phrases, "Cervical Vertigo (CV) and Cervicogenic Vertigo".

You will still find these other terms in overseas texts and articles, so do not abandon it completely in chasing down research, but we do need to continue a trend towards being consistent across our professions.  Therefore...

Let's just stick with good ol' Cervicogenic Dizziness.


Cervicogenic Dizziness Courses and Cervical Vertigo Courses

You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Cervicogenic Dizziness – should you treat the upper trapezius?

Cervicogenic Dizziness / Cervical Vertigo

Simons and Travel 1999 describe myofascial pain (MP) as a common symptom usually caused by myofascial trigger points (MTrPs). The MTrPs in the neck muscles have been associated with a possible source of referred facial and cranial pain and could contribute to the nocioceptive activity occurring with Cervicogenic Dizziness.  The muscle most often affected with the presence of MTrPs in the neck region is the trapezius muscle,  specifically the upper fibers, and this is the most hyperalgesic muscle of the neck and shoulder (Sciotti et al 2001Melegar & Krivickas 2007Fischer 1987).  In fact, it is well established that treating soft tissue dysfunction of the upper trapezius is effective in the management of nonspecific cervical pain (Cagnie et al 2015,  Montañez-Aguilera FJ et al 2010Aguilera FJ et al 2009).

The authors of this manuscript consider addressing MTrPs in the descending fibers of the upper trapezius to be an appropriate treatment for individuals suffering from Cervicogenic Dizziness, however, it may be incomplete and suboptimal location to maximize potential outcomes.   It can have an influence on the functional relevance of the neck in its relationship with the cervico-collic reflex and vestibulo-collic reflex, but may not be a significant factor in modulation of its effects on head-in-space and head-on-trunk posture. All things considered, even though it is a popular location to stretch or treat manually, it may not be as much of a contributing factor of nocioceptive input into dysfunction of head on neck proprioception and self-motion perception.

The following two scenarios are the theoretical concepts to this impression:

  1. Relative Abundance of Muscle Spindles

Neck muscles are richly endowed with muscle spindles and contribute greatly to proprioception of the neck (Voss 1958Cooper 1963Kuklarni et al 2001Liu et al 2003).  The high muscle spindle density and the special features of the muscle spindles in the deep neck muscles allow not only great precision of movement but also adequate proprioceptive information needed both for control of head position and movements and for eye/ head movement coordination.

The number of muscle spindles in relation to muscle mass in a recent anatomical study by Banks RW 2006confirms the greatest abundance is in axial muscles, including those concerned with head position.  The upper trapezius muscle is a high contributor of muscle spindles, but comparably, it is far behind suboccipital musculature, being rated #31 and along the same relative abundance as the adductor pollicis, extensor digitorum brevis, obliquees internus abdominus, omohyoideus, pronator quadratrus and extensor digitorum.  These muscles, due to their location, are of course not primary influence on head-on-neck proprioception.

So, based off of this information and overall thoughts on a patient’s adherence to a home program (keeping 5 exercises or less)— does stretching the upper trapezius, as described in the literature & pictured below, appear to be the most optimal treatment & one we should encourage with patients having cervicogenic dizziness?

trap.jpg

 

Minguez-Zuazo, et al 2016, Malmström et al., 2007; Schenk et al., 2006; Wrisley et al., 2000

2. Influence based off of points of attachment on occiput (from Dvorak J. Manuelle Medizin. 1988)

 

Based off of the cross section of the occipital anatomy shown above, you can question the influence of the upper trapezius, as compared to suboccipital musculature, on the effect of head on neck posture/proprioception.  The surface area of the upper trapezius is significantly less than other muscles of the cervical spine, especially short dorsal musculature of the upper neck.  Therefore, we must take into account the overall influence of the upper trapezius compared to other musculature to optimize patient outcomes and results to improve pain, joint position error and postural stability.

Thus, the theoretical constructs and literature review for the non-articular management of cervicogenic dizziness is unclear and still under scrutiny.   The application of soft tissue management at one location vs another can be determined through a thorough clinical reasoning process and assessment  The type of soft tissue intervention that is most optimal (i.e. dry needling, ischaemic compression, IASTYM, dry cupping, deep massage, etc.) is still under debate, but the authors of this post do feel the location of your intervention can make a difference.

Sign up here for more information on Cervicogenic Dizziness!


Cervicogenic Dizziness Courses and Cervical Vertigo Courses

You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for prices and discounts.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

Cervicogenic Dizziness – Controversial Entity between Professions

Cervicogenic Dizziness / Cervical Vertigo

There is controversy between professions.

Gonzalez and Palacios in 2001 wrote an article, “Cervical Dizziness: A Scientific Controversy” in Fisiotherapia Journal.  The final wording in the manuscript, albeit translated from Spanish to English, basically sums of the controversy that surrounds the diagnosis and treatment of cervicogenic dizziness in one sentence.

For practitioners of physiotherapy and manual medicine, the vertigo of cervical origin is almost unquestioned, treatable and solvable entity mostly, while for professionals otolaryngology and scholars of the vestibular apparatus and balance, their relationship remains hypothetical and in many cases questionable.

Gonzales and Palacios 2001

There is controversy between professions.

To those in the professions of manual medicine and rehab—osteopathy, acupuncture, chiropractic and physical therapy—the diagnosis and treatment of cervicogenic dizziness obviously occurs and can be present in many subsets of different populations.  To anyone who has dealt with this in their office, this seems to be a no brainer as results speak for themselves.  However, outside the manual medicines, including otoneurology and audiology; the diagnosis of exclusion stands concrete and likelihood of referring out is much less likely.  In fact, most of the literature denotes less than a 10% prevalence rate with dizziness from cervical origin and majority of studies consistently outside of the rehabilitation and manual realm do not list it at all under differential diagnosis.

Could cervicogenic dizziness be embellished in the manual medicine fields and neglected in the allopathic medical field?

 

Picture from: Cheever et al 2016

The question remains, what makes the incidence and prevalence so different between the professions?

Is it a business argument?  Obviously manual medicine and rehab can benefit from treating these patients, where medication and imaging does not work.

Is it science?  The diagnosis of dizziness from a cervical origin continues to be under debate and scrutinized (Brandt 1996Brandt/Bronstein 2001).  There is a discrepancy in the pathophysiology, lack of diagnostic criteria including a well established clinical test or a specific laboratory test, and many other diagnoses can be a convincing alternative reason for symptoms.

Is it ethical?  With a lack of a true diagnostic test, unknown epidemiological data points and prognostic time line of improvement—could the manual medicine fields provide unethical treatments— scientific implausible treatments or even fraud?

Is it training?  Anyone in the physical therapy field knows the lack of training in the MSK field by physicians—we fuss about this all of the time.  We contend about their lack of knowledge to refer to us for even less controversial diagnoses.  You can imagine, considering even a small percentage of manual medicine that focuses on cervicogenic dizziness, that medical physicians do not have training or knowledge to refer out to us for this condition.  Just recently, Reneker et al 2015 found a distinct difference between professions regarding utility of clinically diagnostic tests for differentiating cervical and other causes of dizziness s/p concussion.  In fact, three tests, 1) passive joint mobilization, 2) palpation of cervical musculature and 3) joint position error testing were shown to have high utility to diagnose cervicogenic dizziness by PTs (62%, 53% and 47% respectively), but NONE of these were selected by a single neuro-otologist!

There is controversy between professions.

With such discrepancies between the philosophies and clinical approaches between the medical trades, it is no wonder there is never “cervicogenic dizziness / cervical vertigo” is not on a script.  We must meet on the same playing field here and see both sides of the argument with the manual and non-manual fields.

A fair result can only be obtained only by fully stating and balancing the facts and arguments on both sides of each question.

Charles Darwin

It can be challenging to go speak to physicians about this condition as we do not have the juice to provide in regards to evidence.  However, this is an emerging area of practice and the physical therapy field is gaining traction in RCTs by Susan Reid’s work to put more power to our trade.  With that being said, if you want to learn the evidence to present to physicians, either in the elderly, s/p concussion, s/p whiplash or some other head/neck insult—we got you covered because there is controversy between professions. 


Cervicogenic Dizziness Courses and Cervical Vertigo Courses

You can learn more about the screening and treatment process of Cervicogenic Dizzinesss throughIntegrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the entire weekend includes the most up-to-date evidence review from multiple disciplines to diagnose through the “Optimal Sequence Algorithm” and treat through the “Physio Blend”. 

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for prices and discounts.

Sign up for more emails on this topic by clicking here

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

Cervicogenic Dizziness – HINTS Exam

Cervicogenic Dizziness/ Cervical Vertigo

 

The ability to differentiate between central and peripheral causes of dizziness went to another level by the work of Kattah et al in 2009.  The three-step bedside oculomotor examination was found to be more sensitive than early MRI diffusion-weighted imaging and really opened up the eyes (no pun intended) in regards to clinical diagnostic accuracy to the plinth vs imaging examination approach.

Since then, the works of Chen et al 2011 and especially the passion and agenda of several literary pieces by Newman-Toker, have further examined the diagnostic accuracy of the HINTS examination with highly powerful clinical metrics as a screening tool and potentially need for less imaging.

With a sensitivity ranging from 96.8% to 100%, the 3 step process is phenomenal for clinicians!  It definitelybeats any of the PT so called clinical decision rules.

However, I wouldn’t hang my hat on this solely, especially if you’re a PT.  Three main points are made below:

Firstly, unless you have been trained in neuro-otology or neuro-opthalmology, then you may not be as reliable as these guys/gals.  Most of the studies involve an extensive training program and know what to look for in regards to a pathological sign.

Secondly, unless you pound out Direct Access (and most of us seeing dizziness aren’t….), then you aren’t seeing the patients under inclusion criteria set forth in the studies: which is typically a time frame of symptoms less than 7 days. 

Thirdly, all of the studies used a strict inclusion criteria—-resulting in studying moderate to high risk populations—ones with risk factors such as hypertension, diabetes, nausea/vomiting.  Therefore, if you are examining a low risk population, then the HINTS diagnostic sequence may not be as applicable or powerful in its accuracy.

HINTS is a fantastic sequence of objective clinical measures that individually, do not have much influence on a clinical decision, but combined, can be very powerful. Of course we do not rely on one test for diagnoses of other conditions, but a combination of tests/measures highly increases the diagnostic credibility.  I wrote about this with SIJ testing several years ago and more of common practice now in SIJ dysfunction diagnostics.

We teach the HINTS examination, but in context with other clinical features, risk factors and statements in the Subjective Examination and only in combination with other Objective clinical tests that are conceptual to cervicogenic dizziness.  This is what I do in my Optimal Sequence Algorithm.


Cervicogenic Dizziness Courses and Cervical Vertigo Courses

If you want to learn more how to screen your patients and feel MOST confidently in addressing dizziness from a cervical origin, we have it all in our Optimal Sequence Algorithm.  Sign up here for more emails!

You can learn more about the screening and treatment process of Cervicogenic Dizzinesss throughIntegrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the first day provides the most up-to-date evidence review from multiple disciplines to diagnose through the “Optimal Sequence Algorithm” to assist in ruling out disorders and ruling in cervical spine, including determining if single or double entity exists.  

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for prices and discounts.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

Cervicogenic Dizziness – Excerpt from Maitland 1979

Cervicogenic Dizziness / Cervical Vertigo

I am a big believer of standing on the shoulders of giants.  Even though I am not “Maitland trained”—I use his constructs of concordant sign, sensitivity/irritability and several other clinical reasoning aspects in my examination and treatment approaches.  You cannot deny the impact he had on our profession.

I am reaching a decade now (old man status!) of treating in clinical practice and feel like I am seeing more and more that our predecessors are being put down, bashed, exonerated by writings and teachings of that time.   Maybe this is not everyone of course, but through the pits of social media, the bubble is expanding.  I am all about growth and science, but the concepts and principles behind assessing and treatment can still stand strong.  I always remember this foundation and add research on top of it—-to make things positive overall for us, keep reading and pounding out knowledge as the PT profession continues to grow as the best team in musculoskeletal conservative care with updates in research as the “why” of “what” we do is better explained.

Remember—it is always easier to critique than create.

We build off of each other and grow with decades of research, clinical practice and self reflection.  The way I see it—the time line of growth and education is not linear, but builds off like tree rings.

With that being said, it brings me to this excerpt from Maitland in 1979 about differentiating dizziness from arterial dysfunction (i.e. vertebrobasilar insufficiency) to cervical spine dysfunction.

Of course by just reading this, we can mock the lack of clinical metrics behind this thought process (where are the sensitivity and specificity values!?), where is the research citation, how many of your dizziness folks can just go and lie prone??—- However, it is a concept based off of standardized thought processes in our field—-looking at effects of gravity, loaded/unloaded positions, reactions in latency and duration of symptoms, etc.

I would second guess this thought process by saying first we need to evaluate blood pressure, heart rate and appreciate the entire haemodynamic system!  We need to do a thorough screen prior to putting the neck at a risk for mechanical thrombus if the patient walks in with a spontaneous dissection!  We need to rule out a higher probability of dizziness through other benign conditions, such as through a canalith repositioning manuever!  Bam Bam Bam!

The previous paragraph is partly what I teach in my Optimal Sequence Algorithm to diagnose Cerviogenic Dizziness. I feel the components of the examination are the most sound, evidence-based approach based off of concept of diagnosis of exclusion, other reasonable reasons for symptoms, epidemiological data and prevalence/incidence of cervicogenic dizziness in the population.

Interesting enough….DeKlyne first spoke about the VBI test over 75 years ago and this wasn’t mentioned in Maitland’s work from 1979….Maybe he already knew the limitations behind it before we had clinical guidelines and clinical metrics.  I’m certainly glad he didn’t say drop the patient’s head off the edge of the table and see what happens.

Maybe its the history buff in me, but I enjoy looking back at these old articles.  They really can be considered blogs of modern times—-written by 1 author, 3-4 references and straight clinical interpretations.  Don’t give up on our past—but use it positively to build our future.


Cervicogenic Dizziness Courses and Cervical Vertigo Courses

Sign up for more emails on this topic by clicking here

You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the first day provides the most up-to-date evidence review from multiple disciplines to diagnose through the “Optimal Sequence Algorithm” to assist in ruling out disorders and ruling in cervical spine, including determining if single or double entity exists.  

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for prices and discounts.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

Should you Manipulate a patient with Cervicogenic Dizziness?

Cervicogenic Dizziness / Cervical Vertigo

It is now well known through documented basic science research and clinical trials that a subtype of dizzines can occur from dysfunction of the afferent input to the vestibular nuclei arising from the cervical spine, particularly C0-3.  However, the treatment approaches do vary widely in the literature with many accounts showing benefit from therapeutic exercises, education, vestibular rehabilitation, acupuncture, massage, mobilizations and manipulations.

Spinal manipulation continues to be a heavily debated topic due to its possible adverse events & specifically the risk of causing undue stress on the vertebral arteries in the V3 segment with a rotational manuever.  However, it continues to be an effective procedure for cervical spine dysfunctions and may be more effective than massage or mobilizations.

In fact, the effective delivery of manipulation over mobilization/massage could make sense to the practitioner based off of clinical results (personal experience) but also basic science from the findings of Bolton and Budgell 2006, which suggest,

that manipulation provides an immediate and short-term stimulus to the intervertebral tissues and that it is unlikely that deep short intervertebral muscles would be similarly activated when manual therapy is applied to superficial tissues

 

The application of spinal manipulation, especially to the upper cervical spine, is still contentious.  Even with this disputable intervention, there are multiple accounts of the use of spinal manipulation in the literature for the treatment of cervicogenic dizziness (to name a few – Cote 1991, Uhlemann 1993, Bracher 2000Galm 1998).  It has been advocated that the therapy of choice is manipulation (Hulse 1975).

In fact, Heikkila et al 2000 found when comparing acupuncture, NSAIDs and cervical manipulation that,

spinal manipulation may impact most efficiently on the complex process of proprioception and dizziness of cervical origin

 

However, the leading expert in cervicogenic dizziness, Dr. Timothy Hain, disagrees with the use of spinal manipulation with this quote:

we generally think that chiropractic treatment is not a good idea for vertigo of any type, including cervical vertigo

Granted, Hain is speaking of chiropractic but we all know this relates directly to manipulation.

Additionally, Fraix M et al 2013, an osteopathic physician and his group that has studied the effects of osteopathic manipulative therapy in a pilot study in 2010, then again in 2013 and Papa in 2017, purposely did not manipulate the upper cervical spine due to “possibly a pronounced effect on the vestibular system”.  Further, many clinicians note that non-thrust techniques may better serve the suboccipital region.

Thus, the literature is still pending on the use of spinal manipulation for the management of cervicogenic dizziness as it does not always seem logical (Duquesnoy & Catanzariti 2008).   Beyond the scope of this piece but very relevant is the type of manipulation in a patient with dizziness—such as, would it be more appropriate to perform a non-momentum induced thrust vs momentum induced thrust in someone with dizziness induced by head on neck positions?

The author of this manuscript considers spinal manipulation, but knows the effectiveness of other articular and non-articular methods of manual therapy.  It is not to say spinal manipulation isn’t safe, as it can be very safe if provided in the right context.  The application of one over the other entails many facets of patient management, including psychomotor skills, prior experience (patient and clinician) and a thorough assessment.


Cervicogenic Dizziness Courses and Cervical Vertigo Courses

What are your thoughts?  What kind of experience do you have with this topic?

Sign up for more emails on this topic by clicking here

You can learn more about the screening and treatment process of Cervicogenic Dizzinesss throughIntegrative Clinical Concepts, where the author and his wife, a Vestibular Specialist, teach a 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.  

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for prices and discounts.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

 


Cervicogenic Dizziness – the data needs more data!

Cervicogenic Dizziness, Cervical Vertigo, Dizziness Cervical Spine, Physiotherapy, Physical Therapy, Harrison Vaughan, Danielle Vaughan

Cervicogenic Dizziness / Cervical Vertigo

One of my favorite excerpts from an editorial in quite awhile…

Clinicians should quit looking for
overly simplistic answers. Clinical
diagnosis, like producing a great wine,
is complex and requires an appreciation
of the data that can be gathered
within the nuances of patient interaction

Hegedus, Wright & Cook 2017

I do not think I am alone when we all learned clinical tests, or special tests, in PT school, it was one of the coolest things ever! It was gratifying to go from theory to “practice” and actually be able to diagnose something!  Unfortunately, as I continued to learn more, this bubbled busted—and busted with explosive power.

If only it was that easy.

The recent editorial, entitled “Orthopaedic special tests and diagnostic accuracy studies: house wine served in very cheap containers” in BJSM by Hegedus/Wright/Cook (free to access) brings to light the errors associated with clinical diagnostic tests with overall intention of clinicians to utilize clinical reasoning on refined data.

We have these special tests for cervical vertigo / cervicogenic dizziness–i.e. joint position error testing and cervical torsion tests, to aid in our hypothesis—but unfortunately, just like diagnostic tests to rule in hip/shoulder impingement and meniscal tears–these are limited.

 

So when you ask someone about the diagnosis of Cervicogenic Dizziness—back away if he/she quickly throws at you Joint Position Error Testing—even though this is promising, we are better than that.  We should be better than that. JPE testing will simply add more data to the already established data.  The already established data is a stronger foundation, a safer foundation, for your clinical examination.

I have spent the last few years of my clinical career examining every article published (in multiple languages!) coupled with clinical practice to provide the most optimal diagnostic process to put together my Optimal Sequence Algorithm.  In my personal opinion, I think this diagnosis is the most controversial (besides SIJ!), but ultimately takes the gold medal in clinical reasoning due to the often, and intimidating, nature of dizziness in non-benign conditions, including vascular and other central disorders.  No one should be comfortable jumping into the upper neck with someone experiencing dizziness without sound judgement and training.

As previously quoted, “clinicians should stop looking for overly simplistic answers”.  Let me help guide your thought process in this unnerving and overwhelming part of the human body.  These patients are walking in your door—let me help you get them better.


Cervicogenic Dizziness Courses and Cervical Vertigo Courses

You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the author and his wife, a Vestibular Specialist, teach a 2-day course.  Pertinent to this blog post, the first day provides the most up-to-date evidence review from multiple disciplines to diagnose through the “Optimal Sequence Algorithm” to assist in ruling out disorders and ruling in cervical spine, including determining if single or double entity exists.  

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for prices and discounts.

Sign up for more emails on this topic by clicking here

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Canadian C-spine Rule. And HOW does this relate to Cervicogenic Dizziness?

Cervicogenic Dizziness, Cervical Vertigo, Dizziness Cervical Spine

Cervicogenic Dizziness / Cervical Vertigo

The Canadian C-spine Rule is one of the most useful, reliable and valid differential decision making tools in our arsenal. As a very sensitive tool, it is a phenomenal screen for clinicians to rule out a cervical fracture. This is especially important prior to what rehabilitation clinicians do for a living—apply some type of local cervical treatment as it would obviously be an absolute contraindication to treatment.

Even if a PT is unable to fully cite the decision rule, most, if not all are aware of it and its purpose following a low or high trauma. How many of you would treat your MVA and/or concussion patient without having at least plain films performed by a physician? But there is one element that gets overlooked— and that is the ORDER of the various criteria that guide decision making.

As you can see from Figure 1 below, the clinician should NOT ask the patient to actively rotate the neck PRIOR to ruling out high risk factors and THENlow risk factors. There is a top-down approach, which makes the rule THE rule.

Cervicogenic Dizziness, Cervical Vertigo, Dizziness Cervical Spine, Harrison Vaughan, Danielle Vaughan, Physiotherapy, Physical Therapy

Makes sense right?…So then, shouldn’t we think of an optimal sequence, or order, prior to intervening to the cervical spine. This is especially important when you’re talking about a diagnosis of exclusion, one of controversy, one that may not be on a vestibular therapist or physician’s radar—and that is Cervicogenic Dizziness.

But while we talk about ruling out fracture, which is quite easily performed with plain film imaging (and additionally a CT Scan if you get into the emergency literature…); we have to clinically address other major contraindications to intervention—including central disorders, peripheral disorders, vertebral-basilar insufficiency (VBI) and even instability due to ligamentous tears.

These contraindications are MUCH more challenging, more gray but highly important as we are talking about dizziness here!—we don’t have the data points of highly sensitive or specific measures to rule out these conditions but at the same time, we have a very powerful tool to get these patients better, and better quickly. It is certainly a dilemma.

Cervicogenic Dizziness, Cervical Vertigo, Dizziness Cervical Spine, Harrison Vaughan, Danielle Vaughan, Physiotherapy, Physical Therapy

Become more confident at addressing the upper cervical spine. Do your concussion, MVA and BPPV patients a favor. Learn my Optimal Sequence Algorithm for Cervicogenic Dizziness. It takes you through the clinical reasoning, the clinical tests and just as important, the ORDER, of addressing a patient concerned of having dizziness from cervical origin. This is the Canadian C-spine Rule on steroids. Then you can pound out results with the Physio Blend. ALL in a weekend—ALL taught by husband-wife combo who are specialists in manual therapy AND vestibular therapy—BOTH neuro and manual combined—ALL in ONE.


Cervicogenic Dizziness Courses and Cervical Vertigo Courses

You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the author and his wife, a Vestibular Specialist, teach a 2-day course.  Pertinent to this blog post, the first day provides the most up-to-date evidence review from multiple disciplines to diagnose through the “Optimal Sequence Algorithm” to assist in ruling out disorders and ruling in cervical spine, including determining if single or double entity exists.  

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for prices and discounts.

Sign up for more emails on this topic by clicking here

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts