10/3/2016
Department of Physical Therapy
Department of Physical Therapy
OBJECTIVES • Understand the mechanism causing cervicogenic dizziness • Differentiate cervicogenic dizziness from other vestibular disorders • Demonstrate cervicogenic dizziness assessments and treatments • Apply the evidence-based practice to manage cervicogenic dizziness
Cervicogenic Dizziness (CGD) Assessment and Treatment Chia-Cheng Lin, PhD, PT, MSPT Keith Sales, DPT East Carolina University NCPTA Fall Conference October 13, 2016 1
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Department of Physical Therapy
Department of Physical Therapy
Case Report- History
Case Report- Assessments
• 56 year old male involved in MVA • Rear-ended at stop light • No loss of consciousness • Onset of neck pain and dizziness following day • Reports dizziness with head movement and sometimes with positional changes • No complaints of instability
• DHI: 16/100 • Oculomotor Exam • • • • • • • •
Spontaneous nystagmus: negative Gaze holding nystagmus: negative Smooth pursuits: negative Saccades: negative Convergence: positive Slow VOR: negative VOR cancellation: negative but dizziness reported Rapid VOR: negative bilateral but dizziness reported
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Department of Physical Therapy
Department of Physical Therapy
Case Report- Assessments
Case Report- Assessments
• Head shaking nystagmus
• mCTSIB: • Firm Surface: • Romberg eyes • Romberg eyes • Foam Surface: • Romberg eyes • Romberg eyes
• Negative but dizziness reported
• Dix-Hallpike • Negative for nystagmus but reports dizziness
• Head roll test • Negative but reports of dizziness
open: 30 seconds closed: 30 seconds opened: 30 seconds closed: 28 seconds, 30 seconds, 30 seconds
• FGA: 28/30 with score of 2/3 on head turning
• Dynamic Visual Acuity testing • Negative
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Department of Physical Therapy
What is the possible diagnosis? Etiology and Symptoms of CGD Chia-Cheng Lin, PhD, PT, MSPT
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Department of Physical Therapy
Department of Physical Therapy
Causes of Dizziness
Incidence of CGD
• Central problem
• 6.2% (35/561) of people with dizziness presented CGD in 10 years database (Olusesi et al., 2016) • 15-25% of people with whiplash resulted in road traffic accidents develop dizziness (Sterner & Gerdle, 2004)
• Peripheral problem • Non-vestibular • Oculomotor problems • Cardiopulmonary issues • Cervicogenic
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Possible Etiologies • The multisensory mismatch hypothesis • A high density of muscle spindles in the deep intervertebral muscles in the cervical spine • Sensory mismatch between cervical proprioception, somatosensory, vestibular and visual inputs (Bronstein et al., 2011)
Oculomotor Function
Cervico-ocular Reflex (COR)
Balance Function
Perception
• Stimulation at C2 to C3, but not with at C5 or lower • Complements the vestilualoocular reflex (VOR) at lower frequencies
VOR
? Central Vestibular
Peripheral Vestibular
Department of Physical Therapy
Vision
Cervical Proprioception Herdman et al., Vestibular Rehabilitation 4th, Ch. 31, Figure 31.1
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Barnes et al., Acta Oto_laryngological, 1979:88: 79-87
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Department of Physical Therapy
Department of Physical Therapy
Other Proposed Etiologies • Posterior Cervical Sympathetic Syndrome • Vertebrobasilar Insufficiency
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Treleaven ., Manual Therapy 13 (2008) 2-11
Department of Physical Therapy
Department of Physical Therapy
Cervicogenic Dizziness: Symptoms • Neck pain • Dizziness and unsteady after whiplash injuries • Not vertigo, but the patient may report foggy, woozy, swimming, floating, detached • Dizziness more pronounced with cervical motion • Imbalance
CGD Symptoms Chia-Cheng Lin, PhD, PT, MSPT
• Unsteady • No fall
• Ataxia 15
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Department of Physical Therapy
Department of Physical Therapy
Impaired Muscle Activity and sway in People with whiplash-related Chronic Neck Pain
Cervicogenic Dizziness: Symptoms • Musculoskeletal impairment in the cervical spine, thoracic spine and TMJ • ROM limitation • Muscle function impairment • Pain with palpation
• Sensorimotor deficit • Joint Position Error (JPE): > 4.5° (Revel et al., 1991; Chen & Treleaven, 2013) • Head movement control (Treleaven, 2008) • Decreased gain on Smooth Pursuit Neck Torsion Test (SPNT) (Tjell & Rosenhall, 1998; Treleaven et al., 2005 )
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B. Juul-Kristensen et al., J rehabil Med 2013; 45: 376-384
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Department of Physical Therapy
Department of Physical Therapy
CGD Diagnostic Criteria • A diagnosis of exclusion • Rule out the central or peripheral vestibular pathologies
CGD Assessment Chia-Cheng Lin, PhD, PT, MSPT
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Department of Physical Therapy
Department of Physical Therapy
CGD Assessment
21 Wrisley et al., journal of Orthopaedic & Sports Physical Therapy. 2000; 30: 755-766
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Al-Saif et al., Nov Physiother, 201:3
Department of Physical Therapy
Department of Physical Therapy
Medical Screening • Cervical Stability testing: • Sharp-Puser Test • Alar Ligament test • Arterial Patency testing: • Modified Vertebral Artery Test
Medical Screening
• Neurological Exam: • Cranial Nerve Testing • Sensation • Coordination • Deep tendon reflex • Balance assessment
Keith Sales, DPT
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Department of Physical Therapy
Department of Physical Therapy
Modified Sharp-Purser test
Medical Screening
• Test for the transverse ligament. • Performance of test: • One hand stabilize at forehead (patient sitting) • Place head in slight suboccipital flexion • Other hand grasps C2 • Apply P/A force to C2 • Should note a firm end-feel • Positive findings: • Feel Clunk, eyes dilate, Pt reports nausea/dizziness
• Alar Ligaments: • Limits occipito-atlanto-axial rotation and lateral flexion • Pass from the superolateral aspects of the dens to the medial surface of the occipital condyles • Instability can lead to adverse neurovascular events
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Department of Physical Therapy
Department of Physical Therapy
Alar ligament testing
Alar ligament testing— Positive findings
• One hand on patient head (Pt supine)
• If positive stop immediately
• Other hand monitor C2 rotation
• Call for medical assistance/ambulance
• PT to initiate sidebending at OA joint • Should get concurrent C2 rotation to same side • With left sidebending feel Spinous process move right • Must happen immediately
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Department of Physical Therapy
Department of Physical Therapy
Arterial Patency testing • Modified Vertebral Artery Test: • Patient in sitting forward flexes at the hips • Patient then extends and rotates the head • Places c-spine in position of Dix-Hallpike and vertebral artery compression test. • Head position unchanged relative to gravity • Assist in differential diagnosis
Neurological Exam Keith Sales, DPT
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Department of Physical Therapy
Department of Physical Therapy
Neurological Exam • Cranial Nerve Testing • Sensation (light touch/vibration/proprioception/protective sense ) • Coordination (finger to nose/rapid alternating hand movements/Heel to shin testing) • Deep tendon reflex • Balance assessment (mCTSIB/DGI/FGA)
Vestibular Exam Keith Sales, DPT
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Department of Physical Therapy
Department of Physical Therapy
Vestibular Exam
Vestibular Exam
• Oculomotor Exam: • Spontaneous nystagmus • Gaze-Holding nystagmus • Smooth pursuits • Saccades • Convergence • Slow VOR • VOR Cancellation • VOR Rapid Head Thrust
• Testing with Goggles: • Gaze holding nystagmus test • Head shaking nystagmus test • Tragal Pressure • Valsalva Test
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Department of Physical Therapy
Vestibular Testing
Department of Physical Therapy
Dix-Hallpike Test (Anterior/Posterior)
• Dix-Hallpike testing
• Patient’s head rotated 45 degrees horizontally in long sitting • Patient quickly lies down with head hanging over the edge of the bed about 30 degrees • Maintain position for at least 60 seconds. Unless nystagmus has been seen and subsides in a shorter time period
• VOR Hypofunction test
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Department of Physical Therapy
VOR Rapid Head Thrust
VOR Rapid Head Thrust
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VOR Rapid Head Thrust: • Grasp the patient’s head firmly with both hands on the side of their head • Tilt their head down 30 degrees • Have patient look at your nose • Move head slowly back and forth. Let patient know you will be moving their head quickly in small ranges (can defer if patient has pain, surgical history, or significant restriction) • Quickly rotate head to one side and hold it there • Movement must be unpredictable
Positive test: • Look for a corrective saccade to re-fixate on your nose • Note which side had corrective saccade • Test is most likely to be positive with deficits greater than 75% • Due to low sensitivity of test a negative test does not necessarily indicate patient is free of vestibular impairment • This test the lateral canals and superior nerve • Dysfunction could be elsewhere
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Department of Physical Therapy
Department of Physical Therapy
VOR Rapid Head Thrust
VOR Rapid Head Thrust
• Superior Vestibular Nerve: • Horizontal and anterior semicircular canals and utricular
• Performed for anterior and posterior canal
• Inferior Vestibular Nerve: • Saccule and posterior semicircular canal
• Rapid head movement performed in vertical plane
• Head is rotated about 30 to 40 degrees • Also referred to as: • LARP: Left-anterior-right-posterior • RALP: Right-anterior-left-posterior • Positive test: corrective saccade • Test: canals in plane and inferior nerve pathways (superior canal)
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Department of Physical Therapy
Department of Physical Therapy
Head Shake Test
Head Shake Test
• Test for asymmetry in vestibular system
• Velocity storage system allows for clear vision with repeated movement
• Performance of test: • Patient in goggles with eyes open or closed • Shake patient’s head for about 20 cycles • When nearing end of cycles ask patient to open eyes • Once done shaking observe for nystagmus
• Stores the energy of repeated movement • If system is normal stored on both sides so no nystagmus seen • If one side is weak information will not be stored and the stored information on the stronger side will be discharged and cause nystagmus
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Head Shaking Test
Department of Physical Therapy
Components of Vestibular Examination
(2)
• Positive test: • Quick phase nystagmus indicates weakness • Quick phase to stronger vestibular side • Vertical nystagmus indicates central impairment
• Dynamic Visual Acuity: • Visual acuity test with head movements • Must have baseline visual acuity • Test is performed at 2 HZ with us of a metronome • Test is performed with an ETDRS chart (2 to 4 meters) • There should be no more than two line difference from static visual acuity to DVA testing
• Next step: • With quick phase nystagmus may benefit from VNG to confirm vestibulopathy and rule out central • Vertical nystagmus refer out
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Department of Physical Therapy
CGD Assessment: Head-Neck Differentiation Test
Department of Physical Therapy
CGD Assessment: Joint Position Error (JPE) Test • Clinical test to quantify accuracy of accuracy of cervical proprioception
• Neck torsion (Nystagmus) Test • Nystagmus rarely seen • Positive test with nystagmus or dizziness with head fixed/body turned
• Modified method • Laser pointer mounted on a headband • Patient sits 90 cm from target • Closes eyes, moves head maximally, then tries to return to center target • 3 trials • Errors > 4.5° considered abnormal
http://www.skillworks.biz/news/520810 45
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Department of Physical Therapy
Department of Physical Therapy
CGD Assessment: Joint Position Error (JPE) Test
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Department of Physical Therapy
Department of Physical Therapy
Cervical Traction test
CGD Assessment: Balance Testing
• Apply gentle cervical traction. • Improvement in symptoms indicates possible cervicogenic dizziness
• Modified Clinical Test of Sensory Integration of Balance (mCTSIB) • DGI/FGA
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Department of Physical Therapy
Department of Physical Therapy
CGD Treatment • Cervical Spine Management • Manual therapy (Level 2 evidence) (Lystad et al., 2011) • Targeted strength training (Page, 2011) • Cervical Sensomotor Retraining (Jull et al., 2006) • Ocular Motor Retraining • Vestibular Rehabilitation
CGD Treatment Chia-Cheng Lin, PhD, PT, MSPT Keith Sales, DPT
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Department of Physical Therapy
Orthopedic Rehabilitation in treatment of Cervicogenic Dizziness
Department of Physical Therapy
Orthopedic Rehabilitation in Treatment of Cervicogenic Dizziness
• SNAG’s and Maitland mobilization improve dizziness frequency and intensity immediately and at 12 week
• Cervial manipulation reduce neck proprioceptive errors
• 2 to 6 treatment over 6 weeks
(Raid et al., Physical Therapy. 2014:94:466-476)
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Heikkila et al., Manual Therapy. 2000;5:151-157
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Orthopedic Rehabilitation in treatment of Cervicogenic Dizziness
Orthopedic Rehabilitation in treatment of Cervicogenic Dizziness • Cervical Traction • Keep head relatively still with as little change in spatial orientation as possible • No vestibular stimulation • Assess symptomatic response
• Deep cervical flexors training reduced cervical proprioceptive error
O’Leary et al., the Journal of Pain. 2007:832-839
Department of Physical Therapy
Heikkila et al., Manual Therapy. 2000;5:151-157
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Department of Physical Therapy
Department of Physical Therapy
Cervical Sensory Retraining Exercise
Cervical Sensory Retraining Exercise
• Using JPE test for training
• Tracing a pattern with a laser light mounted onto the head
• Parameters • Direction • Speed • posture
• Head control • Pattern • Speed
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Department of Physical Therapy
Department of Physical Therapy
Ocular Motor Retraining • In theory, improve VOR may suppress COR
Case Report Chia-Cheng Lin, PhD, PT, MSPT Keith Sales, DPT
Treleaven. Manual Therapy. 2008:13:266-275
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Department of Physical Therapy
Case report
Dizziness Handicap inventory
• 56 year old male involved in MVA
• Total score: 16/100 (mild handicap)
• Rear-ended at stop light
• Sometimes: • Looking up. • Frustrated. • Difficulty reading. • Ambitious activities. • Turning over in bed. • Strenuous housework.
• No loss of consciousness • Onset of neck pain and dizziness following day • Reports dizziness with head movement and sometimes with positional changes • No complaints of instability
• Always: • Quick movements of head.
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Department of Physical Therapy
Department of Physical Therapy
Assessment
Assessment
• Oculomotor Exam: • Spontaneous nystagmus: negative • Gaze holding nystagmus: negative • Smooth pursuits: negative • Saccades: negative • Convergence: positive • Slow VOR: negative • VOR cancellation: negative but dizziness reported • Rapid VOR: negative bilateral but dizziness reported
• Cervical Stability Testing: negative • VAT: negative • CNS testing: negative
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Department of Physical Therapy
Department of Physical Therapy
Assessment
Assessment
• Head shaking nystagmus: negative but dizziness reported.
• Head-Neck Differentiation Test: Positive.
• Dix-Hallpike: negative for nystagmus but reports dizziness
• Joint Position Error (JPE) Test: • Right Rotation: >6 degrees, 4.5 degrees, 6 degrees • Left Rotation: 4.5 degrees, 3 degrees, 4.5 degrees.
• Head roll test: negative but reports of dizziness • Dynamic Visual Acuity testing: WNL
• Manual traction test: Positive for improved symptoms.
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Department of Physical Therapy
Department of Physical Therapy
Assessment
Treatment
• mCTSIB: • Firm Surface: • Romberg eyes open: 30 seconds • Romberg eyes closed: 30 seconds • Foam Surface: • Romberg eyes opened: 30 seconds • Romberg eyes closed: 28 seconds, 30 seconds, 30 seconds. • FGA: 28/30 with score of 2/3 on head turning.
• Visit one: • Manual traction for reduction of neck pain and dizziness. • X 1 viewing on plain background. • Cervical retractions in supine. • HEP: Cervical retractions and x 1 viewing.
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Department of Physical Therapy
Department of Physical Therapy
Treatment
Treatment
• Visit two: • Manual traction • Unilateral P/A joint mobilizations grade II/III left and right at C2 and C3 • Restricted cervical rotation and hypomobility noted at evaluation • Reproduction of dizziness also reported at evaluation • X 1 viewing on busy background • Cervical sensory retraining exercises (maze) • Cervical retractions in sitting • HEP: cervical retractions, x 1 viewing, tracing
• Visit three: • Manual traction • Unilateral P/A joint mobilizations grade II/III left and right at C2 and C3 • X 1 viewing on busy background while walking • Joint position error test as training • Cervical sensory retraining exercises (maze and pictures) • Cervical retractions in sitting • HEP: cervical retractions, x 1 viewing, tracing
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Department of Physical Therapy
Department of Physical Therapy
Treatment
References
• Visit four: • Patient reports no dizziness in past week. No longer having neck pain • Head-Neck Differentiation Test: negative • Joint Position Error (JPE) Test: WNL • Oculomotor test: negative and no dizziness reported • Static and dynamic stability testing: WNL
• Al-Saif, A., Al-Nakhli, H., Alsenany, S., 2013. Physical thearpy Examination for Patients with Cervicogenic Dizziness. Novel Physiotherapies 3, 4. • Barnes, G.R., Forbat, L.N., 1979. Cervical and vestibular afferent control of oculomotor response in man. Acta Otolaryngol 88, 79-87. • Brandt, T., Bronstein, A.M., 2001. Cervical vertigo. J Neurol Neurosurg Psychiatry 71, 8-12. • Chen, X., Treleaven, J., 2013. The effect of neck torsion on joint position error in subjects with chronic neck pain. Man Ther 18, 562-567. • Ekvall Hansson, E., Mansson, N.O., Ringsberg, K.A., Hakansson, A., 2006. Dizziness among patients with whiplash-associated disorder: a randomized controlled trial. J Rehabil Med 38, 387-390. • Heikkila, H., Johansson, M., Wenngren, B.I., 2000. Effects of acupuncture, cervical manipulation and NSAID therapy on dizziness and impaired head repositioning of suspected cervical origin: a pilot study. Man Ther 5, 151-157. • Jull, G., Falla, D., Treleaven, J., Hodges, P., Vicenzino, B., 2007. Retraining cervical joint position sense: the effect of two exercise regimes. J Orthop Res 25, 404-412. • Juul-Kristensen, B., Clausen, B., Ris, I., Jensen, R.V., Steffensen, R.F., Chreiteh, S.S., Jorgensen, M.B., Sogaard, K., 2013. Increased neck muscle activity and impaired balance among females with whiplash-related chronic neck pain: a cross-sectional study. J Rehabil Med 45, 376-384.
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References •
Lystad, R.P., Bell, G., Bonnevie-Svendsen, M., Carter, C.V., 2011. Manual therapy with and without vestibular rehabilitation for cervicogenic dizziness: a systematic review. Chiropr Man Therap 19, 21.
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Olusesi, A.D., Abubakar, J., 2016. 10 years of Vertigo Clinic at National Hospital Abuja, Nigeria: what have we learned? Eur Arch Otorhinolaryngol.
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Page, P., 2011. Cervicogenic headaches: an evidence-led approach to clinical management. Int J Sports Phys Ther 6, 254-266.
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Reid, S.A., Rivett, D.A., Katekar, M.G., Callister, R., 2014. Comparison of mulligan sustained natural apophyseal glides and maitland mobilizations for treatment of cervicogenic dizziness: a randomized controlled trial. Phys Ther 94, 466-476.
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Revel, M., Andre-Deshays, C., Minguet, M., 1991. Cervicocephalic kinesthetic sensibility in patients with cervical pain. Arch Phys Med Rehabil 72, 288-291.
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Sterner, Y., Gerdle, B., 2004. Acute and chronic whiplash disorders--a review. J Rehabil Med 36, 193-209; quiz 210.
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Tjell, C., Rosenhall, U., 1998. Smooth pursuit neck torsion test: a specific test for cervical dizziness. Am J Otol 19, 76-81.
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Treleaven, J., 2008. Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control. Man Ther 13, 2-11.
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Treleaven, J., Jull, G., LowChoy, N., 2005. Smooth pursuit neck torsion test in whiplash-associated disorders: relationship to self-reports of neck pain and disability, dizziness and anxiety. J Rehabil Med 37, 219-223.
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Works, S., Physical Thearpy Educaiton specialists.
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Wrisley, D.M., Sparto, P.J., Whitney, S.L., Furman, J.M., 2000. Cervicogenic dizziness: a review of diagnosis and treatment. J Orthop Sports Phys Ther 30, 755-766.
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