Cervicogenic Dizziness Differential Diagnosis & Treatment

1. Cervicogenic Dizziness Differential Diagnosis & Treatment Jessica Pyatt, SPT Regis University July 2010 Case Presentation

4. Objectives • By the completion of this case presentation the audience will: • Be able to indicate potential patient presentation/ history items in individuals with cervical spine associated dizziness • Be able to transfer evaluative T&M to the differential diagnosis of individual’s with / without cervicogenic dizziness. • Ascertain potential treatment options for patients with cervicogenic dizziness

6. Why Should I Care? • 8 Million primary care visits for dizziness / year • Individuals over 65 y/o: • 39% of falls partial attributable to dizziness • Whiplash Associated Disorder • Resulting Dizziness in: • 40-80% • 20-58% • 1/3 of individuals with neck pain also have dizziness • Prolonged disability / pain Humphreys 2008; Reid 3005

7. Patient Presentation • Female, 62 y/o • L > R scapular / upper trap and neck pain • Headaches & Dizziness: • along temples, behind eyes with nausea and dizziness • “head does not belong to my body” “disorientated/off” • Light headedness: • stands too fast / up at night • Falls 2-3 x / week • Worse: • with/at work, stress, computer use, rotating head & neck • Better: • pain medication, self message, up and moving around (walking/not at computer)

8. Medical History • Breast cancer: • L mastectomy, Tran Flap reconstruction, R lumpectomy & radiation • Osteoporosis • Scoliosis • Arthritis: neck, low back, • Jt pain & swelling • HTN ∞ • Stomach / GI / IBS • Depression ∞, anxiety ∞(including sleeping medication) • Difficult concentrating, fatigue & stress • Patient report of unremarkable imaging ***** ∞ Medications

9. Observation • Guarded • Slight forward head posture • “cranial shift’’/ upper cervical SB • Nodding of head / neck to look over glasses • L shoulder elevation • Flat thoracic spine • Thoracic: R convexity scolosis • Palpation: • Thoracic right prominence throughout / R rotated, • B upper trap / scapular/ RTC tenderness / spasm • B 1st rib tenderness

10. Screening Exam • BP 124/78 • Strength: WNL • Sensation: • WNL to light touch bilaterally • Reflexes: 2+ symmetrical • Hoffman’s: negative • Cervical ROM: • Flexion: 56 (WNL) • Extension 75 (WNL)∞ “tight” • Sidebend: L = 57 R = 46∞ “tight” • Rotation: L = 68 R = 55limited, slight provocation

11. Differential ??????

12. Wrisley, 2000; Landel 2010; Brandt, 2001 Differential • BPPV • Perilymphaticfistual • Labyrinthine concussion • Migraine –related vertigo, photophobia • Central / peripheral vestibular dysfunction • VBI – vetebral basilar insufficiency • Vestibular system / vestibular nerve • Brain injury / central vestibular • Orthostatic Hypotension / vascular • Double vision – glasses • Oculomotor • Drugs / alcohol intoxication

13. “Diagnosis of Exclusion” • Rule Out Red Flags: • Oculomotor tests • Nystagmus-??? • Smooth pursuit - ???? • Vetebral Artery • Peripheral : • Position • Hallpike • ENG/VNG • Orthostatic Hypotension

14. Cervicogenic Dizziness Description • Vague • Not spinning / vertigo like • Unsteady • Spacey • Disconnected • Disoriented • Floating • Lightheaded – without faint feeling • Difficult concentrating

15. Special Tests • Sharp Pursuer: Negative • AlarLigamant testing (SB & rotation): negative • Transverse Ligament Test: • Negative ??? • Prolonged hold 30 seconds = slight nausea • On a bad day / retesting • OA nodding / AA rotation • Symmetrical • AA slight limitation

16. Special Tests • Sustained End Range Rotation: Negative bilaterally • No change in blood flow at C1/2, C5/6 during hold • Reduction on return to neutral • Rest period for pre-manipulative / manual testing Zaina 2003 • Spurlings: • Bilaterally reproduced upper cervical pain, no UE s/s • Compression: • reproduces L sided neck pain • CRLF: + Right

17. Cervical vs Vestibular Move body under head: + symptoms suggests cervical involvement + with body turn L / R cervical rotation Head and neck together as one unit: + symptoms central or peripheral vestibular involvement

18. Sensory Systems

19. Sensory

20. Cervicogenic • Vague dizziness description • Episodes with neck movement • Imbalance • Occipital/ bi-temporal headaches • Episodic dizziness minutes to hours ***** • “head not straight” • Not walking straight • Falls • Impaired ROM • Oculomotor abnormalities

21. Cervicogenic Dizziness • Dizziness & Neck Pain Together • Postural control / increased sway • Cervical muscle function • DNF • Extensors • Joint position errors • Temperature hypersensitivity • Post-traumatic stress

22. Neck Pain • Manual PT of Cervicogenic Dizziness: A Systematic Review (Reid 2005) • Low quality – Level 3 Evidence • Positive / Significant improvement with manual PT Wrisley, 2000: 73-82% of patients reduced s/s with manual PT Karlberg, 1996 Malmstrom 2007

23. Self “SNAG” Reid, 2008

24. Postural Control • Balance Training

25. Posture & Ergonomics

26. Cervical Flexion Test • Staged test of deep cervical flexor motor control • Air filled stabilizer sensor • Start: 20 mmHg, 2 mmHg increments • Hold 5 or 10 seconds • No SCM contraction / no head lift • Results: 26 mmHg x 10 sec Jull, 2000; Falla 2003, 2004 • WAD average 23+/- 1.3 mm, • Asymptomatic average 28 +/- 1.7 mmHg Deep neck flexor endurance: 23 seconds

28. Cervical Extensors

29. Joint Position Error • 90 cm from wall • Eyes closed • Angle = tan-1 (error distance / 90 cm) • 7.1 cm = 4.5 degrees • Greater than 4.5 degrees = impairment • Lee, 2006 test, retest reliability of assessing jt position error • Kristjansson 2009 Expert Opinion / Clinical Review • Lee, 2006: Test-retest reliability of cervicocephalickinestathic sensibility • Jull 2007: Reduction in jt position error with training • Revel, 1994

31. Outcomes…....Still to Come • Dizziness VAS: 6/10 average at intake • NDI : • 6-2-10: 14/50 or 28% • 6-16-10: 24/50 or 48% 6-16 • FABQPA: 12/24 • FABQW: 20/42 • Pain VAS: 6-7/10 ---- 2/10 ---- 3-4/10 • Decreased frequency of dizziness sxs / week

32. Du, du, du, du…du, du, duuuu. Du, du, du, du DU, dudududuuu. • Name one sxs that must accompany ‘dizziness’ to be cervicogenic in origin…… • Cervicogenic dizziness is described as……….. • Normal deep neck flexor endurance is ______. • Normal cervical joint position error is less than ________ degrees.

33. Psychosocial Aspects • Emotional • Disorientation • Depression • Anxiety • Fear of open spaces • Inability to perform ADLs • Employment (Gudleski, 2005) 7-14 Days

34. References • Alix ME, Bates DK. A proposed etiology of cervicogenic headache: the neurophysiologica basis and anatomic relationship between the dura mater and the rectus capitis minor muscle. J Manipulative PhysioTher. 1999; 22: 534-539. • Brandt T, Bronstein AM. Cervical vertigo. J NeurolNeurosurg Psychiatry. 2001. 71: 8-12. • Eldridge L, Russel J. Effectiveness of cervical spine manipulation and prescribed exercise in reduction of cervicogenic headache pain and frequency: a single case study experiemental design. Int J Osteo Med. 2005; 8: 106-113. • Landel R. Cervicogenic dizziness: perspectives on evaluation and treatment. American Physical Therapy Association. Combined Sections Meeting. San Diego, CA. 2010 • Falla DL, Jull GA, Hodges PW. Patients with neck pain demonstrate reduced electromyographic activity of the deep cervical flexor muscles during performance of the craniocervical flexion test. Spine. 2004; 29: 2108-2114. • Falla DL, Campbell CD, Fagan AE, Thompson DC, Jull GA. Relationship between cranio-cervical flexion range of motion and pressure change during the cranio-cervicla flexion test. Manual Ther. 2003; 8: 92-96. • Gudleski GD. Major disasters, stress and GI symptos: the September 11th tragedy and its effect on persons with irritable bowel syndrome. State University of New York at Buffalo Thesis. 2005. DAI-B 66/08, p. 4482. • Huijbregts P. Vidal P. Dizziness in oprthopaedic physical therapy practice: classification and pathophysiology. J Man ManipTher. 2004; 12: 199-214. • Jull GA. Deep vertical flexor muscle dysfunction in whiplash. J Musculo Pain. 2000; 8: 143-154. • Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B. Retraining cervical joint position sense: the effect of two exercise regimes. J Ortho Resear. 2007; 25: 404-412.

35. References • Karlberg M, Magnusson M, Malmstrom EM, Melander A, Moritz U.Postural and symptomatic improvement after physiotherapy in patients with dizziness of suspected cervical origin. Arch Phys Med Rehbil. 1996; 77: 874-882. • Kristjansson E. Treleaven J. Sensorimotor function and dizziness in neck pain: implications for assessment and management. J Orthop Sports Phys Ther. 2009; 39: 364-377. • Lee HY, Teng CC, Chai HM, Wang SF. Test-retest reliability of cervicocephalic kinesthetic sensibility in three cardinal planes. Manual Ther. 2006; 11: 61-68. • Malmstrom EM, Karlberg M, Melander A, Magnusson M, Moritz U. Cervicogenic dizziness – musculoskeletal findings before and after treatment and long-term outcome. DisabilRehabil. 2007; 29: 1193-1205. • Ogince M, Hall T, Robinson K, Blackmore AM. The diagnostic validity of the cervical flexion-rotation test in C1/2-related cervicogenic headache. Manual Ther. 2007; 12: 256-262. • Reid S, Rivett DA, Katekar MG, Callister R. Sustain natural apophyseal glides (SNAGs) are an effective treatment for cervicogenic dizziness. Manual Ther. 2008; 13: 357-366. • Reid SA, Rivett DA. Manual therapy treatment of cervicogenic dizziness: a systematic review. Manual Ther. 2005; 10: 4-13. • Revel M, Minguet M, Gergory P, et al. 1994. Changes in cervicocephalic kinesthesia after a proprioceptive rehabilitation program in patients with neck pain: a randomized controlled study. Arch Phys Med Rehab 75: 895–899 • Strunk RG, Hawk C. Effects of chiropractic care on dizziness, neck pain, and balance: a single-group, preexperimental, feasibility study. J Chiro Med. 2009; 8: 156-164. • Zaina C, Grant R, Johnson C, Dansie B, Taylor J, Spyropolous P. The effect of cervical rotation on blood flow in the contralateral vertebral artery. Manual Ther. 2003; 8: 103-109.

36. Questions???