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

Should you use Cervical Distraction to diagnose Cervicogenic Dizziness?

Cervicogenic Dizziness / Cervical Vertigo

Cervical Distraction Test, or also known as Foraminal Distraction Test or Neck Distraction Test, is a common orthopedic test.  It has historically been utilized and studied to determine nerve root compression indicating a diagnosis of cervical radiculopathy, especially in the prevalent lower cervical spine.  The diagnostic utility is fair to poor (less than a coin flip) in regards to screeningbut has promising value to be a specific test.  Additionally, the test is 1 of 5 variables that, if positive, indicate that a patient would benefit from cervical traction through a preliminary CPR back in 2009.  The latter makes common sense and for most of you reading, it has probably been preached to you in your graduate studies.  Nevertheless, a positive test is not an encouraging screen to help your clinical reasoning to rule out nerve root compression, but can aid later in your examination to rule it in.

Cervicogenic Dizziness (CGD) or also known as Cervical Vertigo, is caused by an aberrant or erroneous somatosensory afferent input from the cervical spine into the central nervous system centers causing vague disorientation and dysfunction in postural control.  The particular origin of altered somatosensory dysfunction could arise from multiple structures but typically stems from the upper cervical spine proprioceptive and muscle spindle sensitivity.

The question remains, should you use Cervical Distraction to diagnose Cervicogenic Dizziness?

Considering it is well understood that the dysfunction is in the upper cervical spine associated with Cervicogenic Dizziness, the reader can question why a diagnostic test, typically associated with the lowercervical spine, is utilized as diagnostic criteria?

The use of Cervical Distraction in the diagnostic criteria for the diagnosis of Cervicogenic Dizziness, to my knowledge, has been declared in two reports from the literature.

The first comes from Rob Landel, who can be considered one of the leaders in the education of CGD, describes a case report at the WCPT in 2015.  Clinical findings suggested there was no central or peripheral vestibular involvement, CNS or cardiovascular impairment, and that vestibular migraine was unlikely.  Based on previous experience with patients presenting similarly, a trial of cervical traction in sitting was attempted and proved successful, suggesting CGD. Accordingly supine manual traction was applied, with symptom resolution that lasted for 15–20 minutes. The patient was instructed in home traction using a towel tied to a doorknob, DNF and JPE exercises.

The second comes from a recent 2017 review entitled, “How to Diagnose Cervicogenic Dizziness” by Reiley et al.  This is a phenomenal article by the way and I highly recommend reading.  It follows along very nicely with my Optimal Sequence Algorithm (previous blog posts herehere, and here).   Quoting Richard Clendaniel’s book in 2014,  the authors state, “a reduction of dizziness symptoms in response to cervical traction implicates involvement of the cervical spine and is more consistent with CGD than with vestibular dysfunction. It is best to perform traction with the patient sitting in order to minimize the effect of gravity on the vestibular system”.

The question remains, should you use Cervical Distraction to diagnose Cervicogenic Dizziness?

Within several other disciplines (chiropractic, osteopathic, surgical), it is hypothesized that the dysfunction in the upper cervical spine stems mostly from pathology in the lower cervical spine.  The dysfunction is mostly described as a facet joint problem or cervical disc problem, especially degenerative in nature.  From a physiotherapist’s viewpoint, this can be conjectured from a postural issue, such as forward head posture, placing the upper cervical spine in extension in relation to a more flattened, mid-cervical spine.  In a nutshell, this can lead to overactivity of the superficial cervical musculature and increased tone in the upper cervical extensors.

So yes, a positive Cervical Distraction Test (abating concordant symptoms) could very well be diagnostic in the diagnosis of Cervicogenic Dizziness.  However, I would be highly suspicious of this test aloneas one test is no test, and used only after excluding other causes.  Outside of the above two citations, the use of this test as in inclusion criteria is absent in every other piece of literature, including the most rubust RCTs for Cervicogenic Dizziness to date.  Therefore, we have to question its validity in this specific population.  As a diagnosis with controversy between professions, you have to have a powerful and step-wise examination approach.

Even in a diagnostic test that is considered specific, we have to be aware of the non-specific effects of a practitioner’s hands on someone in a relieving manner as this could cause a great deal of false-positives. Asking a patient if their symptoms are better after you distract their neck (which is relieving to anyone!) can certainly make a non-mechanical cause of dizziness more comforting.

Therefore, using the Cervical Distraction Test for Cervicogenic Dizziness judiciously, alongside appropriate clinical reasoning and in the correct order in examination can assist in your final diagnosis.


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

Finally. After 17 years, it's here.

CervDizziICC.jpg

Cervicogenic Dizziness

Through my professional life, I have always heard it takes 17 years for evidence to be implemented into clinical practice.  With technological advancements in social media and search capabilities to gain knowledge from literary papers, I feel this number has to be much less nowadays.

While teaching this past weekend, I brought this up.  One of the participants has been treating for 41 years, yes, 41 years!  She quickly reminisced of how different things were back then to share with the class.  Of course obtaining more knowledge and reading papers isn't a quite Google search and follow someone popular on social media platforms.  During those years you actually had to go and search for what you're looking for professionally.  Makes us feel lazy now doesn't it...

The timing of 17 years is coincidental in the context of Diagnosing Cervicogenic Dizziness.  Anyone who has had any interest in this topic has read Diane Wrisley's work: Cervicogenic Dizziness - a Review of Diagnosis and Treatment in our own JOSPT from the year 2000.  It is well cited throughout other profession's works and continues to be almost a "gold standard" go-to when talking about this topic.  You can find it easily online here.

17 years later, in 2017, Alexander Reiley and colleagues right down the road from me at Duke University came out with an updated paper entitled, "How to diagnose Cervicogenic Dizziness".  Within the journal Archives of Physiotherapy, this is an excellent article and has some updated information on the topic.  As an open access article, you can also access it easily online here.

Some of you may think, Harrison---why are you sharing these articles as this is what you and your wife teach during the entire first day on your course circuit!  The purpose of our course is to get this information OUT THERE---to propel our profession forward as the go-to providers to treat Cervicogenic Dizziness / Cervical Vertigo.  We have the background training, the openness in our diagnostic and treatment approaches, the integration of vestibular and manual therapies specialities to change lives.

Also---as I said this past weekend to class participants---we have known about Mark Laslett's SIJ cluster for 10 yrs to diagnose SIJ dysfunction---but we continue to search how to best to TREAT it.

Well---you can always read in papers how to diagnose something, but we do offer our solutions to TREAT it on our second day.  :)

Coincidence of 17 years with update in this diagnostic process system in our professional journals...maybe so.


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

 

 

Should you recommend surgery for Cervicogenic Dizziness?

CervDizziICC.jpg

Cervicogenic Dizziness

It is well established that conservative treatment should be the primary choice of intervention for non-specific neck pain as the benefit of surgery over conservative care is not clearly demonstrated.  For rehabilitation professionals, the use of exercise therapy and/or manual therapy is obviously the most appropriate decision and should always be utilized prior to most invasive, risky procedures.

This is echoed in the Cervicogenic Dizziness / Cervical Vertigo literature as well.  We have three systematic reviews demonstrating the benefit of non-surgical and non-pharmacological interventions, specifically manual therapy, for these patients.  The high level of evidence all originated in 2005, then again in 2011 and even though just showing effectiveness of acupuncture, endorsed recently in 2017.  Although only three SRs, I think this is very positive considering a condition not well studied and continues to carry the burden of controversy.

Even with substantial evidence showing the effectiveness of conservative care, specifically manual therapies, for Cervicogenic Dizziness / Cervical Vertigo, there are still several citations illustrating success following surgery.

Here is a glimpse of the literature with accompanying conclusion:

Yang Y et al 2007

“Percutaneous laser disc decompression can decrease intradiscal pressure, increase local temperature and remove the spasm of the vertebral artery while providing a remarkable therapeutic effect for the treatment of cervical vertigo.”

 Ren L et al 2014

“Excellent outcome in 18 out of 35 patients who underwent percutaneous laser disk        decompression”

Li J et al 2014

“Good results following more extensive cervical surgery”

Park J et al 2014

“Patient vertigo disappeared after surgical decompression of transverse foramen of C1”

Liu XM et al 2017

“ACDF provided a good resolution of cervical vertigo in a retrospective study of 116 patients”

Yin HD et al 2017

“Radiofrequency ablation nucleoplasty improves the blood flow in the narrow-side vertebral artery in 27 patients diagnosed with cervical vertigo and illustrates the therapeutic effect on cervical vertigo. Radiofrequency intradiscal nucleoplasty can be used as a minimally invasive procedure for treating cervical vertigo”

You can see a trend in the just the last few years indicating success of vertigo/dizziness after surgical procedures.  As an evidence-informed practitioner or even a vestibular specialist who isn’t trained in treating the neck, and recognizes lack of consistent relief in your patient, you may seek out this research and consider referring on to a surgeon.  Before you do so, let’s dive into the most recent article with surgical success to jack into a clinical reasoning discussion.


 

Patients/Methods: Of 145 patients with cervical spondylosis and dizziness, 116 underwent anterior cervical decompression and fusion and 29 underwent conservative treatment. All were followed up for one year. The primary outcomes were measures of the intensity and frequency of dizziness. Secondary outcomes were changes in the modified Japanese Orthopaedic Association (mJOA) score and a visual analogue scale score for neck pain

Results: There were significantly lower scores for the intensity and frequency of dizziness in the surgical group compared with the conservative group at different time points during the one-year follow-up period (p = 0.001). There was a significant improvement in mJOA scores in the surgical group.

Conclusion: This study indicates that anterior cervical surgery can relieve dizziness in patients with cervical spondylosis and that dizziness is an accompanying manifestation of cervical spondylosis.

Out of China, Dr. B Peng and his colleagues recently had this article published in the Bone & Joint Journal (not the best journal but higher impact factor than JOSPT). This is a level 2 multi center prospective cohort study—not bad when considering level of evidence as we have very few studies higher up on the chain and most involve the same name of Susan Reid & her colleagues from the land of Australia.

From initial glimpse of methodology, results and conclusion (you know we all typically look at the abstract…), my thoughts are that if my patient has arthritis and dizziness, then if they have surgery, they will have less intensity and frequency of dizziness compared to conservative route.

The first thing I did was to look at what type of conservative treatment was performed.  Here is the description:

Conservative treatment included physiotherapy, intermittent cervical immobilization with a collar, nonsteroidal anti-inflammatory drugs and rest.

This doesn’t tell us much what kind of physiotherapy was performed (stabilization exercises, heat/ice, e-stim, massage, squeezes for the shoulder blade squeezes with theraband, neck ROM—hell we don’t know!).  We don’t know what was meant by rest, or what was meant by intermittent immobilization of the spine (does anyone do this nowadays anyway?).  For all purposes, it could be the Physio Blend buffet style…but doubtful.

The second thing I did was look at the type of patients that were recruited.

Between March 2014 and March 2015, 157 patients with cervical spondylotic radiculopathy and/or myelopathy from three spinal centres (General Hospital of Armed Police Force, Beijing; 304th Hospital, Beijing; Changzheng Hospital, Shanghai) were enrolled in the study.

Additionally, the patients had failed conservative treatment (3 months of treatment!) prior to potentially having surgery—-34 of the 157 patients declined surgery—but continued with conservative treatment—and this was the group that surgery was compared to!  I’m sure the patients who continued with PT after 3 months were stoked to continue more of the same cervical immobilization, rest, NSAIDs and general physiotherapy….

The third thing I did—write this blog.


Big key points:

This is not a bash against the article—I thought it was well written and authors were open to the limitations in the conclusions.  They even stated the patients selected for study were for myelopathy/radiculopathy and not dizziness!  But, knowing the time and effort that goes into reading research in the profession—the title and abstract could be misleading to the consumer and I felt this blog would be beneficial to my rehabilitation colleagues.

Just like any condition we treat, this paper exemplifies a double entity.  Yes, the patients had improvement in dizziness following the procedure, but I would really say these patients had success of cervical pain due to cervical spondylotic radiculopathy and/or myelopathy, NOT cervicogenic dizziness.

This paper also exemplifies the notion that dizziness can arise from the neck, and can improve with intervention!  So yes, still can be controversial in the medical eyes, but this group sought out improvement in dizziness following the procedure indicating a cause/effect relationship.

Further, if you’re a vestibular therapist seeing patients you think that symptoms could be arising from the cervical spine, don’t just pass on to your orthopedic mate in the clinic.  Get some training, some real training.  We can help you with that.


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

Everyone loves a buffet – Cervicogenic Dizziness Style

CervDizziICC.jpg

Cervicogenic Dizziness

Happy 2018 everyone!  This year, I am completing my first decade of work as a Physical Therapist—wow, can’t believe it.  I believe I am now considered an oldie…the dinosaur…in our field!

I hope all of my colleagues and readers are continuing to enjoy the profession. Like you all, I continue to have the challenges, failures, and tribulations with clinical practice.  Hopefully these get fewer and fewer between but still very normal even with experience—its the beauty of physiotherapy…of healthcare.   I continue to aim high and hopefully the defeat gets buried away, hidden underneath the hours you spend beating on your craft.  Continue to pursue greatness to propel yourself and our field.  Always remember, have fun as we are very fortunate to change lives everyday.

Over the years, the pursuit of additional training and knowledge has led me down many paths.  As you all are aware if reading this blog over the past year, professionally, I have taken the challenge of being part of a continuing education company,; specifically, teaching the Differential diagnosis & the Manual and Therapeutic Exercise Management of Cervicogenic Dizziness.

The beauty of this condition is that it is a very specific diagnosis—one of which is still controversial, yet, responds very well to multiple treatment approaches throughout the literature.  Unlike treatment approaches in other fields of medicine, you would think that a specific diagnosis would lead to a specifictreatment.  But, just as gray as PT can be, this just isn’t true.  Cervicogenic Dizziness can improve with a taste of ALL we have to offer.  Hell, we can just talk to them and give some general exercises and they improve…but can we do more?  Can we achieve better results?!

This is what the Physio Blend is all about.  It is my specific approach incorporating a taste of ALL we can offer that is achievable no matter your skill level and previous training; including signature soft tissue spots, upper cervical spine joint work, vestibular, pain-relieving and sensorimotor exercises—all packaged together smoothly to maximize results.

It is really our whole package of what we do as a profession.  Its the whole buffet.

buffetline.jpg

If you want to treat concussion, treat whiplash, treat BPPV or even the elderly with balance disturbances, AND be evidence-based in 2018, this is where it’s at.  Feel more confident in your differential diagnosis and be more confident in attacking the upper neck as your resolution this year. You may push and prod on the upper neck and make change, but always know, the desserts are at the end of the buffet.  You may be missing other applicable manual therapies, other applicable exercises, and other applicable confidence to give the entire experience that your patients deserve.


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