Cervicogenic Dizziness: A Review of Diagnosis and Treatment

Journal of Orthopaedic & Sports Physical Therapy
2000;30(12):755-766
Cervicogenic Dizziness: A Review of
Diagnosis and Treatment
Diane M. Wrisley, MS, P7; NCS1
htrick J. Sparto, PhD, PT2
Susan I. Whitney, PhD, P7; ATC3
Joseph M. Furman, MD, PhD2
The diagnosis of cervicogenic dizziness is characterized by dizziness and dysequilibrium
that is associated with neck pain in patients with cervical pathology. The diagnosis and
treatment of an individual presenting with cervical spine dysfunction and associated
dizziness complaints can be a challenging experience to orthopaedic and vestibular
rehabilitationspecialists. The purpose of this article is to review the incidence and
prevalence, historical background, and proposed pathophysiology underlying cervicogenic
dizziness. In addition, we have outlined the diagnostic criteria, evaluation, and treatment of
dizziness attributed to disorders of the cervical spine. The diagnosis of cervicogenic
dizziness is dependent upon correlating symptoms of imbalance and dizziness with neck
pain and excluding other vestibular disorders based on history, examination, and vestibular
function tests. When diagnosed correctly, cervicogenic dizziness can be successfully treated
using a combination of manual therapy and vestibular rehabilitation. We present 2 cases, of
patients diagnosed with cervicogenic dizziness, as an illustration of the clinical decisionmaking process in regard to this diagnosis. ) Orthop Sports Phys Ther 2000;30:755-766.
therapists must learn how to elicit
a thorough history that will provide the information necessary to
make decisions about treating the
patient o r referring the patient to
another health care practitioner.
We borrow the definition of cervicogenic dizziness from Furman
and Cassw: "a nonspecific sensation of altered orientation in
space and dysequilibrium originating from abnormal afferent activity from the neck." Cervicogenic
dizziness does not result from vestibular dysfunction and, therefore,
Key Words: cervical vertigo, dysequilibrium, whiplash
rarely results in true vertigo.'O Cervicogenic dizziness is most often
associated with flexion-extension
injuries and has been reported in
he diagnosis and treatment of an individual presenting
patients
with severe cervical arthriwith cervical spine dysfunction and associated complaints
tis,
herniated
cervical disks, and
of dizziness can be a challenging experience to orthopaedhead
tra~ma."J."~
In these paic and vestibular rehabilitation specialists. The differential
tients,
complaints
of
ataxia, undiagnosis may include cervicogenic dizziness, benign paroxsteadiness
of
gait,
or
postural imysmal positional vertigo, perilyrnphatic fistula, labyrinthine concussion,
balance
associated
with
neck pain,
migraine-related vertigo, and central or peripheral vestibular dysfunclimited
neck
range
of
motion,
or
tion. The decision to treat the patient o r refer to another healthcare
headache
p
r
e
d
~
m
i
n
a
t
e
.
'
This
~
.
~
professional is essential to providing appropriate and timely care. Given
article will focus on the incidence
the potential seriousness of some of the causes of dizziness, physical
and prevalence, historical background, and proposed pathophysiI Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsology underlying cervicogenic dizburgh, Pittsburgh, Pd.
ziness.
In addition, we will address
Department of Otolaryngology, School of Medicine, Department of Physical Therapy, School of
Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pd.
the diagnostic criteria, evaluation,
I Department of Otolaryngology, School of Medicine, Department of Physical Therapy, School of
and treatment of dizziness attribHealth and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pd; Center for Rehab Seruted to disorders of the cervical
vices, Vestibular Rehabilitation Center, Pittsburgh, Pd.
Send correspondence to: Pdtrick 1. Sparto, University of Pittsburgh, Department of Physical Therapy, spine. When diagnosed and treat6035 Forbes Tower, Pittsburgh, PA 15260. E-mail: [email protected]
ed properly, the symptoms of cer-
vicogenic dizziness can be reduced, resulting in improved function.""
INCIDENCE AND PREVALENCE
The concurrence of dizziness complaints and cervical spine dysfunction is commonly associated with
flexionextension injuries (whiplash) acquired in a
motor vehicle accident. It is estimated that every year
0.1% of the population experiences a whiplash inju~-y.~-@'
Significant disability can result, with an estimated 20% of individuals who experience whiplash requiring greater than 20 weeks to return to work.@'
Furthermore, a significant proportion of those who
experience whiplash complain of neck pain months
after the injury occurred?
The primary symptom of whiplash is neck pain,
which is reported by 62-100% of study participants
in initial evaluations after the hipl lash.^^^^^^^^^^^^^ The
next most common symptom is headache (primarily
occipital in location), which occurs in 6 M 7 % of the
study population^.^^.^^.^^^ Although dizziness, vertigo,
and dysequilibrium d o not frequently occur at the
initial presentation to the emergency department,".57
20-58% of individuals who have sustained a closed
head or whiplash injury will experience these symp
toms.58.64.71
Vestibular system disorders are included in the differential diagnosis of patients with dizziness associated with cervical spine dysfunction. For example, dizziness following neck injury may be due to vestibular
system pathologies, brain injury, or cervicogenic dizz i n e s ~ . ~ Several
' . ~ . ~ groups have examined the occurrence of vestibular disorders following whip
lash.21.24.4n..-.71 Table 1 provides operational definitions for frequently used terms regarding vestibular
pathology that may be unfamiliar to the reader. Routine tests that are performed for the diagnosis of vestibular disorders are described in Table 2. Abnormalities have included deficits in smooth eye pursuit,
normal or hypoactive caloric vestibular responses,
spontaneous and positional nystagmus, and impaired
postural ~ o n t r o l . ~ ~ ~ ~ . ~ ~ - ~ ~
Reports of dizziness with other types of neck dysfunction are certainly not as prevalent as with whip
lash. However, several case reports have demonstrated dizziness in patients with cervical spine spondylosis and cervical muscle spasms. Ryan and CopeGSreported 3 cases of dizziness that they attributed to
cervical spondylosis. The symptoms of 3 patients with
dizziness and painful posterior cervical muscles reduced with an injection of anesthetic into the posterior neck m ~ s c l e s .Cervicogenic
~~.~
dizziness may be
a result of whiplash injury, other forms of cervical
spine dysfunction, o r spasms in the cervical muscles.
756
HISTORICAL BASIS AND PATHOPHYSIOLOGY OF
CERVICOGENIC DIZZINESS
Brown2" relates that the contribution of the cervical region to balance has been studied experimentally in animals for 150 years. Strong connections have
been demonstrated between the cervical dorsal roots
and the vestibular nuclei with the neck receptors
(such as proprioceptors and joint receptors) playing
a role in eye-hand coordination, perception of balance, and postural adjustments. Brownz0provides a
comprehensive review of this literature. With strong
connections between the cervical receptors and balance function, it is understandable that injury or pathology of the neck may be associated with a sense of
dizziness or dysequilibri~m.~
Dizziness that is presumed to occur due to dysfunction in the cervical spine has been recognized
since early in the 20th century. Symptoms of cervicogenic dizziness were thought to be due to abnormal
input from cervical sympathetic nerves based on the
work of Barrelo and Lieow% in the 1920's. They experimentally induced dizziness, tinnitus, and Horner's syndrome (constriction of the pupil, ptosis, ipsilateral loss of sweating) by injecting anesthetic into
the upper cervical region. No sympathetic or vascular
changes were subsequently identified that could account for these symptoms and this theory lost favor.m
In the 1950's, there was a resurgence of interest in
the idea that dizziness may be related to pathologies
of the cervical r e g i ~ n Ryan
. ~ and Cope" introduced
the term "cervical vertigo" and although vertigo as
defined in Table 1 is rarely a symptom, cervical vertigo has remained the most popular name for the focus of Ryan and Cope's paper. These authors theorized that cervicogenic dizziness was due to abnormal afferent input to the vestibular nucleus from
damaged joint receptors in the upper cervical region. They described 3 types of patients that display
this syndrome: patients with cervical spondylosis, patients treated with cervical traction, and patients following neck trauma. Graf4 found that he could relieve dizziness considered to be related to cervical
muscle dysfunction by injecting anesthetic into the
posterior cervical muscles. This finding supported
Ryan and Cope's- theory that abnormal afferents
from the cervical region caused dizziness and dysequilibrium.
Others have experimentally produced a "reversible" lesion in the cervical region and observed deficits in balance and vision. CohenZJdescribed deficits
in balance, orientation, and coordination in primates
following injection of anesthetic in the upper 3 cervical dorsal roots. Biemond and de Jong15 reported
that injection of anesthetic into the neck of rabbits
induced positional nystagmus. Later, de Jong and
colleaguesw found that injection of anesthetic
around the dorsal roots of rabbits, cats, and primates
J Orthop Sports Phys Ther-Volume 30-Number 129 December 2 0 0
TABLE 1. Definition of terms.
Term
Ataxia
Dizziness
Dysequilibrium
Saccades
Visual smooth pursuit
Unsteadiness of gait
Vertigo
Labyrinthine concussion
Mild brain injury
Benign Paroxysmal Positional Vertigo (BPW)
Perilymphatic fistula
Whiplash
Definition
The inability to produce smooth, coordinated movements.12
A nonspecific term that describes an altered orientation in space. It may include
sensations of light-headedness, heavy-headedness, faintness, giddiness, unsteadiness, imbalance, falling, waving, or fl~ating.~
The inability to maintain upright post~re.~
A rapid change in eye position, usually to shift gaze quickly from one object to
an~ther.~'.~'
The ability to maintain gaze on a moving object.75
Abnormal sway or gait pattern during amb~lation.~~
An illusory sensation of motion (rotational, translational, or tilting of the visual
environment)of either self or surro~ndings.'~
A peripheral vestibular impairment caused by head trauma that usually is manifested by unilateral hearing loss and unilateral reduced peripheral vestibular
function. Patients will typically complain of fluctuating vertigo and dysequilibrium.38
Injury to the brain characterized by brief loss of consciousness or coma less
than 1 hour.
A disorder caused by the presence of debris in the semicircular canal. Patients
will typically complain of short episodes of vertigo when rolling over in bed,
reaching up, or bending over. The Dix-Hallpike Maneuver is used to diagnose
BPW. If present, the patient will present with nystagmus that begins 5-15 seconds after the patient is positioned and lasts for 30 seconds to 1 minute.
Symptoms are usually worse in the morning and improve throughout the
day."
An abnormal connection between the middle and inner ear spaces. Patients typically present with symptoms of unilateral hearing loss, tinnitus, dizziness, dysequilibrium, and ~ertigo.'~
Injury to the cervical vertebrae or associated soft tissue caused by a sudden forward or backward acceleration of the vertebral co1umn.l
TABLE 2. Common vestibular laboratory tests that may be performed on persons with cervicogenic dizziness.
Vestibular test
Description of the test
Criteria for a normal result
Oculomotor screening5J4
Patients are asked to sit in an otherwise darkened room,
fixate on a target, and watch vertical lines move in
front of them. The electronystagmography (ENG) electrodes that surround the eyes record eye movements.
Abnormal responses may indicate central nervous system dysfunction.
For horizontal canal testing, patients are placed in the
supine position with their head flexed 30". Warm or
cold air or water is placed in the ear canal alternately
while the ENG electrodes record eye movements. This
is the only test that can localize the side of the lesion
in the ear.
Patients are asked to lie supine with their head turned to
the right and left and also to lie completely on their
left and right sides. The eye movements are recorded
in each position in darkness.
Patients sit in a darkened room while they are moved
slowly to the right and left in a rotating chair. Eye
movements are recorded. This test assesses the vestibulo-ocular reflex.
The accuracy and timing of the
eye movements are compared
with normative data.
Caloric te~tirigsl~.~~
Positional testing5J4
Rotational testinpa
P o ~ t u r o g r a p h y ~ ~ , ~ ~ ~ ~ ~ ~ ~ ~ ~ ~The patient stands on a forceplate during 6 increasingly
complex visual and somato-sensory conditions (Sensory organization testing). The forceplate records the
amount of sway that the patient experiences. Postural
sway is also assessed during linear and angular perturbations of the platform.
J Orthop Sports Phys Ther*Volurne 3O.Nurnber 12 December 2000
The symmetry and intensity of
the eye movements are compared with normative data.
Nystagmus is not normally seen
in persons without vestibular
dysfunction.
The examiner determines the
symmetry and intensity of the
response from the recordings
and compares it to normative
data.
Patient's scores are compared to
age-related normative scores.
757
produced nystagmus and ataxia. In humans, injecting jects with whiplash-associated disorder or other cervianesthetic around the cervical dorsal roots caused dys- cal dysfunction has led some to consider using postuequilibrium, a strong sensation of imbalance and be- rography as a diagnostic t e ~ t . ~ . ~ . ~ ~ ~ ~ ~ ~ ~ " W o w e v e r ,
these tests cannot be performed in the clinic without
ing pulled towards the side of the injection. Wap
specialized equipment and have not been validated.
neri4 discovered that the sensation of tilting or fallFurthermore, increased postural sway is a nonspecific
ing could also be evoked by electrical stimulation to
finding that is also evident in patients with vestibular
the cervical muscles. Accordingly, the aberrant input
injury.'
from the cervical proprioceptors is considered to be
The lack of a definitive diagnostic test increases
related to muscle spasms in the sternocleidomastoid
the challenge of diagnosing cervicogenic dizziness.
and upper trapezius muscle^.^^.^.^.^^ Hence, this eviTherefore, the diagnosis of cervicogenic dizziness is
dence leads to the current theory that cervicogenic
dizziness results from abnormal input into the vestib- suggested by (1) a close temporal relationship beular nuclei from the proprioceptors of the upper cer- tween neck pain and symptoms of dizziness, including time of onset and occurrence of episodes, (2)
vical region. Furthermore, the interconnections beprevious neck injury or pathology, and (3) eliminatween the cervical proprioceptors and the vestibular
tion of other causes of dizziness.% It is important to
nuclei may contribute to a cyclic att tern,^ such that
take a detailed history and perform a comprehensive
cervical muscle spasms contribute to dizziness and
examination in order to eliminate other causes of
dizziness contributes to muscle spasm, although the
dizziness. The details of the history and physical excausal relationship is unclear.
amination are discussed below.
DIAGNOSTIC CRITERIA
Cervicogenic dizziness is a diagnosis of exclusion
(ie, the diagnosis is usually based on the elimination
of the other competing diagnoses, such as vestibular
or central nervous system pathologies). The develop
ment of a robust clinical diagnostic test for cervicogenic dizziness has been elusive. The neck torsion
nystagmus test, or head-fixed, body-turned maneuver
is considered by some to identify cervicogenic dizziness." This test requires the head of the patient to
be stabilized while the body is rotated underneath.!'"% Theoretically, the neck proprioceptors are
stimulated while the inner ear structures remain at
their resting ~ t a t eNystagmus
.~
is elicited in a positive test. However, this test has not been demonstrated to be specific for cervicogenic dizziness. Oosterveld et alx' reported that 64% of 262 patients with
neck pain who presented to an otolaryngology department post-whiplash had nystagmus elicited with
the head-fixed, body-turned maneuver. On the other
hand, it has been demonstrated that up to 50% of
subjects without cervical spine pathology have also
demonstrated nystagmus with the head-fixed, bodyturned m a n e ~ v e r . ~ ~
A, positive
" ~ . ~ ~ response (nystagmus) may not indicate pathology, but may instead be
a manifestation of the cervical ocular reflex.%
Others have explored the use of vestibular and
postural sway testing for the diagnosis of cervicogenic dizziness. Tjell and Rosenhallio examined smooth
pursuit eye movements in patients with whiplash,
acute vestibular pathology, or central nervous system
dysfunction. Based on reduced velocity of eye movements during the tracking tasks when the subjects'
heads were turned, the researchers were able to classify the individuals who had dizziness post-whiplash
with a sensitivity of 90% and specificity of 91%. In
addition, evidence of increased postural sway in s u b
PHYSICAL THERAPY EVALUATION
Patient History
When a physician refers a patient to physical therapy, the referral may or may not provide a direction
for the history taking. Certainly, a referral for "dizziness, evaluate and treat" by a primary care physician
would not be as helpful as one for "cervicogenic dizziness, evaluate and treat" by an otolaryngologist or
neurologist. Furthermore, one would expect a more
thorough screening procedure for vestibular or central nervous system disorders by the physicians specializing in inner ear disorders. Since not all therapists have the benefit of receiving referrals from
these specialists, this article assumes that the only information provided to the therapist is from the patient. Furthermore, because of the imprecise use of
the terms dizziness and vertigo in the general community, we will approach the patient with no preconceived notions about the qualitative nature of the patient's symptoms.
Obtaining a thorough history from a patient presenting with dizziness is critical to making a decision
regarding the proper care of the patient. The first
step is to ask the patient to describe their symptoms.
Unfortunately, there are many words used to describe symptoms of dizziness and vertigo, and it is often difficult for a patient to provide specific descrip
tions. Table 3 includes some typical ways that patients describe their symptoms. If a patient's descrip
tion of their symptoms is consistent with vertigo,
then a central or peripheral vestibular disorder is
suspected. However, cervicogenic dizziness cannot be
completely ruled out as a diagnosis.
The duration and frequency of the symptoms, as
well as their temporal relationship with the neck
1 Orthop Sports Phys Ther-Volume SO. Number 12. December 2000
TABLE 3. Common words used to describe symptoms of patients presenting with balance and vestibular disorders.
Patient's words
What the words suggest
Dizziness
Spinning
Headache
My neck hurts.
People tell me that my head is not straight.
I feel like I am going to fall.
I can't walk straight.
I am having trouble reading.
I am tired.
I feel like everything is moving when I am in a busy
environment with motion and distractions.
My vision is jumping.
Swimming sensation in their head
This is a nonspecific finding and could be either cewicogenic dizziness or a
peripheral or central vestibular disorder.
The patient could have a central or peripheral vestibular disorder, although
spinning of short duration often suggests Benign Paroxysmal Positional Vertigo (BPPV) if there is no central nervous system dysfunction.
Often patients complain of an occipital or bitemporal headache with cewicogenic dizziness. Tension headaches are more localized and are described as
a ring around the head or in the frontal area. Migraines can be very severe,
tend to be unilateral, and may cause sensitivity to light and motion.
It is often seen in people with whiplash or labyrinthineconcussion disorders.
This is more common in central vestibular disorders than peripheral disorders.
This is often seen in ce~icogenicdizziness and also with head trauma. This is
rarely seen in persons with peripheral vestibular disorders.
This is common in both cewicogenic dizziness and in peripheral or central
vestibular disorders. It is a nonspecific symptom.
This could be seen in cewicogenic dizziness, with a peripheral vestibular disorder, or with central vestibular disorder.
This is also a nonspecific symptom. It could be cewicogenic dizziness or a
peripheral or central vestibular disorder. It might be helpful to test their eyes
with a vision chart to see if there is any loss of acuity. If the problem exists
only with head movement, it may suggest a vestibular abnormality.
This is a very common complaint in persons with vestibular or balance disorders.
This complaint of space and motion discomfort is common in persons with
migraine, anxiety-panic, and in persons with peripheral vestibular disorders.
The visual surroundings will jump with oscillopsia and it usually suggests a
peripheral vestibular disorder of either 1 or both ears.
Nonspecific but can suggest that there is central nervous system dysfunction.
pain, can aid in the diagnosis of cervicogenic dizziness. The time (how long ago) and mode of onset
(gradual, sudden, or associated with injury) should
be determined. Symptoms resulting from cervicogenic dizziness typically are associated with injury or cervical spine disease, however, their onset may be sudden or gradual and occur days to years following the
injury. Next, if the dizziness is episodic, the number
of events per day or week and the duration of each
event should be elicited by the therapist. Table 4 lists
the frequency and duration expected for various
causes of dizziness. Cervicogenic dizziness typically
occurs in episodes lasting minutes to hours. Information regarding conditions that exacerbate or relieve
the symptoms is also helpful. Symptoms resulting
from cervicogenic dizziness will be increased with
neck movements o r neck pain and decreased with in-
terventions that relieve neck pain (modalities, analgesic, anti-inflammatory or muscle relaxant medication). Finally, the therapist should ask the patient for
any history of balance difficulties and falls related to
the symptoms.
A similar type of history regarding neck pain
should be obtained, including a specific description
of symptoms, location, time and mode of onset, and
aggravating factors. Dizziness related to active movement or changes in head position with or without
neck pain may lead one to think that there is a cervical component. To entertain a diagnosis of cervicogenic dizziness, however, the therapist must be able
to correlate the onset and duration of the dizziness
symptoms with the neck dysfunction (ie, dizziness accompanied by neck pain or with head movements).
In addition to the complaints about dizziness and
TABLE 4. Duration and frequency
.
. of common causes of dizziness.
Cause
Common symptoms
Frequency
Duration
Benign Paroxysmal Positional Vertigo4'
Vertigo
Episodic
Seconds
Cewicogenic d i z ~ i n e s s ~ ~ . ~ ~
Perilymphatic fistula16
Dizziness, dysequilibrium
Dysequilibrium, vertigo
Episodic
Episodic
Minutes to hours
Seconds to minutes
Labyrinthine concussion42
Central vestibular dysfuncti~n~~
Vertigo, dysequilibrium
Dizziness, dysequilibrium
Episodic
More constant
Hours to days
Days to weeks
J Orthop Sports Phys Ther.Volume SO. Number 12. December 2 0 0
Related factors
Related to head position,
usually worse in AM
Related to head position
Vertigo during Valsalva
maneuver
Increases with fatigue
May be seen in combination with inner ear
~atholoeies
759
TABLE 5. The appropriate action to be taken by a physical therapist based on various additional symptoms in patients presenting with dizziness or
vertigo.
Unexplained or new onset of
symptoms that may require
immediate medical attention
Constant vertigo
Feeling of being pushed to one side
Facial asymmetry
Swallowing dysfunction
Speech problems
Oculomotor dysfunction (cranial
nerves Ill, IV, VI)
Rosis
Vertical nystagmus
Loss of consciousness
Repeated, unexplained falls
Changes in sensation
Severe headache
Upper motor neuron signs and
symptoms
Symptoms that require
nonemergent referral to
an otola~n~oloaist
Constant dizziness
Unilateral hearing loss
New onset of tinnitus
Aural fullness (stuffiness in ear)
Ear pain
Transient vertigo
Symptoms that can be
treated by a physical
therapist
Transient dizziness
Cervical pain
Limited cervical range of motion
Radicular upper extremity symptoms
Headache
Balance complaints
Jaw pain
Visual sensitivity
Nausealvomiting*
Anxiety, fatigue*
Although physical therapists may not provide direct intervention for these symptoms, reduction in dizziness may alleviate them.
neck dysfunction, the therapist should be careful to
ask further questions regarding other symptoms that
may be perceived by the patient, as listed in Table 5.
All the symptoms in the first column of Table 5 suggest a possible central nervous system pathology that
may need immediate attention. It is always preferable
to speak with the patient's primary care or referring
physician before seeking emergent care. Symptoms
listed in the second column of Table 5 (which are
frequently reported after sustaining a whiplash injury) require a visit to an otolaryngologist because they
are consistent with inner ear pathology. In our opinion, these symptoms d o not require urgent attention.
Finally, the third column lists typical secondary symp
toms that may be reported at the time of the initial
evaluation. We believe that these symptoms are within the scope of physical therapist practice and thus
may be addressed directly.
If a patient experiences transient true vertigo, then
a peripheral vestibular ailment or benign paroxysmal
positional vertigo is more likely. The time course of
the symptoms also may provide a clue to the pathology. Dizziness or vertigo due to perilymphatic fistula
may have an onset 24-72 hours after head trauma
and episodes may last minutes to hours.%." Nausea
and vomiting are common signs of acute vestibular
pathology. Benign paroxysmal positional vertigo may
occur more than 2 weeks after head t r a ~ m a ;and
~
characteristically lasts less than a minute after a
change in position.47 Cervicogenic dizziness may occur anywhere from days to months or longer after an
injury of the head and neckFOwith a time course of
minutes to hours per episode.
Examination
Once the history is complete, the therapist can
proceed to rule in o r out the competing differential
diagnoses. Note that the examination procedure presented here does not represent the complete exam a
vestibular rehabilitation specialist would use for any
patient presenting with nonspecific dizziness,'" nor
does it represent the complete exam that an orthopaedic physical therapy specialist would use for a patient with nonspecific cervical dysf~nction.~%ther,
it is an outline of a thorough
- examination the authors would use to rule in or out a diagnosis of cervicogenic dizziness. The order in which the assessments are performed is at the discretion of the therapist, but an attempt was made to discuss the examination in a logical sequence.
The flow chart (Figure) depicts the decision-making process that the physical therapist should go
through to arrive at a diagnosis of cervicogenic dizziness or other pathology that may present similarly to
cervicogenic dizziness. In the first step, the therapist
determines if the patient with a chief complaint of
dizziness or vertigo has neck pain, either at rest, with
active neck movement, or with palpation of the neck
musculature. This step is important because, by definition, a diagnosis of cervicogenic dizziness is excluded in a patient without neck pain.'" If the patient has
dizziness with neck pain, a diagnosis of cervicogenic
dizziness should be considered because cervicogenic
dizziness might account for both the dizziness and
the neck pain. However, there is a possibility that the
patient may have neck pain as a secondary impairment due to a vestibular disorder or may have 2 s e p
arate diagnoses, 1 to account for the dizziness and 1
to account for the neck pain. To help establish a diagnosis of cervicogenic dizziness, other vestibular disorders such as benign paroxysmal positional vertigo,
Meniere's disease, labyrinthine concussion, and migraine-related vestibulopathy must be ruled out. Although the sensitivity and specificity of vestibular
J Orthop Sports Phys Ther.Volume 30. Number 12. December 2000
/
injury or patholog/
I
no
i
PPV, vestibular disorder,
andlor cewicogenic dini
I
I
L-J
Dix-Hallpike
and refer to MD for
no
Vestibular disorder, andlor
cewicogenic dizziness
/
?-,
4
Canalith
repositioning
Maneuver
normal results
vestibular testing
Vestibular
disorder
Co-treat (Case 1)
FIGURE. Decision tree used for a ~atientwho Dresents with dizziness or vertigo and neck pain. BPW indicates benign paroxysmal positional vertigo;
MD, medical doctor; VR-PT, vestibhar rehabilitition physical therapist.
function tests are not very high,4.%14.17.X'-3'II~!l.40.7.9 the
use of vestibular function tests in conjunction with
history and clinical examination provides the clinician with a reasonable idea of the involvement of the
vestibular system.
In the early part of the examination, the therapist
should measure the patient's active cervical range of
motion, preferably while the patient is sitting. This is
done for several reasons. The first is to simply measure any impairment in the range of motion. Second, the therapist should inquire about any symp
toms of pain or dizziness elicited by the active movements. Changes in pain or dizziness can be quantified by comparing the patient's rating of these
symptoms with the rating obtained before movement. Third, the active movement can be used to determine if the patient has adequate range of motion
for subsequent tests that the therapist may perform,
such as the Dix-Hallpike maneuver for benign paroxysmal positional vertigo (BPPV), which requires 30"
of cervical extension and 45" of cervical rotation.:"
J Orthop Sports Phys Ther.Volume 30-Numher 12eDecemher 2 0
With the patient sitting, the therapist may also perform vision tests and an upper quarter screening
procedure (range of motion, manual muscle testing,
accessory motion testing, sensation and reflex testing
of the upper extremity and cervical region).
The therapist may test for posterior semicircular
canal BPPV using the Dix-Hallpike mane~ver.~-'"he
therapist must make certain that the patient has adequate active range of motion, given that the cervical
spine of the patient is placed in 45" of rotation and
30" of extension so that the posterior semicircular canal is stimulated in the vertical plane. The Dix-Hallpike maneuver is initiated by having the patient attain the long-sitting position while the therapist rotates
the patient's head 45" to one side and brings the patient into supine quickly while extending the head
30". The patient is asked to report any symptoms
while the therapist observes the patient's eyes for
nystagmus. If the patient cannot tolerate a traditional
Dix-Hallpike maneuver because of pain or decreased
cervical range of motion, the position can be modi-
ties, postural reeducation, active range of motion,
fied by having the patient lie down to the side with
massage, balance retraining, trigger point injection,
the head turned so the back of the head is toward
muscle relaxants, and use of a soft cervical collar
the surface and the nose is pointing up. Tilt tables
or mobilization tables can be used to put the patient during the acute phase.lfi.20.'2~26~27.M.44.5'.65.M~77 HOweVer, few controlled clinical trials have been performed
in a position to stimulate the posterior semicircular
to determine the effectiveness of these interventions.
canal by having the patient rotate the head approxiThree clinical trials that propose intervention for
mately 45' to the side and lowering the head of the
cervicogenic dizziness are summarized in Table 6.
bed into a trendelenberg position. A Dix-Hallpike
These authors report that 7342% of patients receivmaneuver is said to be positive if the patient reports
symptoms of spinning and rotational, upbeating nys- ing some form of manual therapy had a reduction in
their symptom^.^"^'.^^ It is the authors' experience
tagmus is observed with a latency of 5-15 seconds
and a duration of 30 seconds to 1 minute. If the Dix- that patients may require both manual therapy and
vestibular rehabilitation to achieve relief of both cerHallpike maneuver is positive, BPPV can be treated
vical and vestibular symptoms.
by performing a canalith repositioning maneuverw
Two case reports will be used to illustrate the diagor by instructing the patient in Brandt-Daroff exercisnosis and treatment of suspected cervicogenic dizzies.'" A single treatment of the canalith repositioning
maneuver has been reported to eliminate symptoms
ness. One case report describes a patient who was
in 72-78% of patients with BPPV, with complete ressuccessfully treated using a combination of both
olution of 91% after 2 treatment^.^^.^^.^^.^^.^" However, manual therapy and vestibular rehabilitation (Case
only one randomized controlled clinical trial has
1). The second case report describes a patient initialbeen performed." Brandt-Daroff exercises have been ly evaluated by an orthopaedic physical therapist and
given cervical spine range of motion exercises and
reported to result in a remission of symptoms in
98% of patients when performed over a 2-week perisubsequently treated with vestibular rehabilitation
therapy alone (Case 2).
od]" no randomized controlled clinic trial has been
performed to confirm this. If the therapist is not
skilled in these interventions, then referring the paCase 1
tient to a physical therapist o r physician specializing
The first patient is a 49-year-old woman who prein balance disorders is appropriate.
sented with complaints of dizziness, nausea, and dyseA negative Dix-Hallpike maneuver should lead to
quilibrium 8 months after a motor vehicle accident.
management of the neck impairments and referral
She described fluctuating symptoms that occurred
to a physician for vestibular testing. The diagnosis of
cervicogenic dizziness is then made only after no ves- daily. The symptoms were exacerbated by head rnovements or with lying down and would last for hours.
tibular abnormalities are found by the physician.
She related that the symptoms were worse on days
Considering either diagnosis, the therapist may dewhen the neck pain and headaches were worse. She
cide to cotreat with, o r refer to, a vestibular rehabilidenied any tinnitus, aural fullness, or hearing loss.
tation physical therapist.
Vestibular function testing results including electronysPatients with cervicogenic dizziness may complain
tagmography (ENG), calorics, positional testing and
of poor balance. Balance disorders may be manifestrotational chair, provided by the physician, were nored by difficulties in standing with a narrow base of
mal.
support, walking with head turns, reaching outside
On initial evaluation, she rated her neck pain as
the base of support, turning and looking over one's
8-9/10 on a verbal analog scale with 0 meaning no
shoulder, standing o r walking on compliant surfaces.
decreased environmental lighting, and eye closure. A pain and 10 meaning the worst imaginable pain. Her
cervical range of motion was not impaired; however,
full balance assessment may include pen and paper
any head or neck movements increased her symp
tests such as the Activities-specific Balance Confitoms of dizziness. She presented with tenderness to
dence scale?* as well as functional tests like the Dynamic Gait Indexm and the Berg Balance Test.13 The palpation and palpable trigger points (areas of increased pain) in her bilateral upper trapezius, scaleClinical Test for Sensory Interaction in Balance
(CTSIB) is another popular test that is used to assess nes, and sternocleidomastoid muscles. She dernonstrated an inability to maintain focus on an object
the patient's ability to use vestibular cues while conwhile turning her head (impaired functional use of
flicting visual and proprioceptive cues are presentthe vestibular-ocular reflex) and complained of ined.'j7
creased nausea during activities that required head
and eye movement. During static balance testing, she
PHYSICAL THERAPY INTERVENTION
was able to maintain stance with feet together for 6
Historically, the intervention for cervicogenic dizzi- seconds with her eyes open, but was unable to mainness has included manual therapy (mobilization and
tain the position with her eyes closed. She was unable to maintain tandem stance (sharpened Romberg)
manipulation), mechanical traction, physical modaliJ Orthop Sports Phys Ther .Volume SO. Number 12. December 2000
TABLE 6. Summary of articles that address outcome of treatment for cervicogenic dizziness.
Study
Subjects
Wing and Hatgrave-Wilson, 1 974n
80 subjects with history of neck
pain and vertigo, 46% with
neck injury.
Control group
Type of study
Neurodologic evaluation
Intervention
Frequency and duration
None.
Case series.
96% had normal ear, nose, and
throat examination, 80% had
normal electronystagmography
examination including caloric
and positional testing.
Manipulation, immobilization in
soft cervical collar, instruction
in proper sleeping positions.
Not specified.
Karlberg et al, 199652
17 patients, mean age 37 years, with diagno- 50 patients with suspected cervisis of cervicogenic dizziness. Subjects rancogenic dizziness, 31 patients
domized to receive immediate ~hvsical
therapy or wait 2 months and i k a t e physical therapy.
17 healthy subjects.
Prospective, randomized, clinical trial.
Ear, nose, and throat and neurological exam
excluded extra-cervical causes of dizziness.
Soft tissue treatment, stabilization exercises
of the trunk and cervical spine, passive
and active range of motion exercises, relaxation techniques, home training programs, and minor ergonomic changes at
work.
5-20 weeks with median number of visits =
13.
Outcome measures
Results
Ear, nose, and throat with head
flexed, extended or rotated
with eyes open and closed;
subjective report of symptom
relief.
73% of patients demonstrated
improvements in ear, nose,
and throat with head and neck
movements. 53% of patients
reported complete relief of all
symptoms. 36% had significant improvement and returned to normal activity without medication.
Calm et al. 1998"
Subjective intensity of neck pain; intensity
and frequency of dizziness; variance of vibration and galvanic-induced body sway.
There was no change in symptoms of neck
pain or dizziness between the time when
initially tested and just prior to beginning
physical therapy, for the group that started
treatment late. 82% of ~atientsre~orted
improvement of dizzinks followi;lg physical therapy. 82% of patients reported improvement of neck symptoms. Postural performance significantly improved following
phvsical theraw ( P < .05).
or single limb stance without upper extremity s u p
port. On the sensory organization test of computerized dynamic posturography, she demonstrated a pattern of multisensory dysfunction. Her composite
score was 19/100 (normal for her age would be 70/
100) with increased sway in conditions 1-3 and falls
on all trials of conditions 4-43 (for additional information about posturography test conditions, refer to
Furman"). She demonstrated ataxic gait with her
eyes open and closed.
The patient was given a diagnosis of cervicogenic
dizziness based on the association between her symp
toms of dizziness and neck pain, history of a flexionextension injury of the cervical region, and the exclusion of other peripheral vestibular pathology. She
was initially seen weekly for physical therapy and
treated with soft tissue massage, mobilization, and
deep massage to her cervical musculature with emphasis on massaging the trigger points in the sternocleidomastoid muscle. She was instructed in a home
exercise program of gentle range of motion exercises, followed by application of ice to be performed 24 times each day. In addition, she was provided a
J Orthop Sports Phys Ther.Volume 30. Number 12. December 2 0 0
with cervical spine dysfunction
(group A) and 19 patients
without cervical spine dysfunction (group B).
None.
Case series.
Ear, nose, and throat and neurological exam excluded extracervical causes of dizziness.
Both groups treated with manual
therapy.
"Intensive outpatient physical
therapy" for up to 3 months.
Subjective improvement in dizziness.
Group A: 77.4% reported improvement of symptoms of
dizziness; 5 patients completely free of dizziness. Group B:
26.3% reported improvement
of symptoms; none were completely free of symptoms.
transcutaneous electrical nerve stimulation (TENS)
unit and instructed in its use to provide pain relief
and to decrease the spasms in the cervical muscles.
She was also instructed to begin a progressive walking program and to perform simple balance activities
such as standing with the eyes closed and standing
feet together with small amounts of sway.
At the end of 3 weeks, the patient reported that
her pain level had decreased from 8-9/10 to 3/10
on a verbal analog scale more than 50% of time. She
reported only a single episode of dizziness and nausea in the previous week. She demonstrated significant improvement in the static balance tests. She
demonstrated no veering while walking with head
turns or while walking with her eyes closed. Although she demonstrated significant improvements
in pain control and balance, she continued to describe dizziness and nausea with head turns, standing
or moving with her eyes closed, with movement in
the environment or with conflicting visual cues (ie,
walking in store aisles or in environments with busy
patterns on the floor or walls). Due to these syrnp
toms of dizziness and the finding of gaze instability
at initial evaluation, it was decided to begin vestibular rehabilitation to decrease her reliance on visual
and somatosensory cues and increase her use of vestibular cues for balance. The vestibular rehabilitation
program consisted of eye exercises (VORxl and
VORx2) to improve the efficacy of the vestibular-ocular reflex and balance exercises with graded exposure to varied sensory
The patient was seen for 17 visits over a period of
5 months. At discharge, she reported that she was
close to 100% of her premorbid function. She continued to complain of left occipital pain and mild
dizziness with quick movements and visual conflict.
She reported her pain level was less than 2/10 on a
verbal analog scale 90% of the time. On evaluation,
cervical range of motion and strength were not impaired and she was able to perform the static balance tests (Romberg, sharpened Romberg, and single limb stance) for at least 30 seconds with her eyes
open and closed. Her computerized dynamic posturography score had also improved to within normal
limits, with a composite score of 81/100 and normal
amounts of sway on all 6 conditions of the sensory
organization test. She was able to ambulate community distances (distances of 1-2 miles) without assistance and with no evidence of sway.
Case 2
The patient is a 49-year-old female who experienced a motor vehicle accident that resulted in a
flexionextension injury of the cervical region one
year ago. She was referred to an outpatient orthopaedic clinic with a diagnosis of neck pain and dizziness. The patient's chief complaint was of dizziness
and imbalance, which she related to changes in head
position. She had only 25% of normal cervical flexion, extension, right side bending, and right rotation. She also had approximately 50% of normal
range of motion for left side bending and left rotation. The orthopaedic therapist saw the patient for 1
visit and provided her with neck stretching exercises
in an attempt to increase her range of motion and
then referred her to vestibular rehabilitation.
The patient stated that she previously had experienced an acute onset of vertigo but had not been
vertiginous for several months. Her Activities-specific
Balance Confidence scale (ABC) score was only 27%,
indicating that the patient perceived that she was not
confident with her balance (100% is the best score
that can be achieved). The ABC is a tool used to assess confidence in 16 different activities of daily living and has been used with persons with vestibular
dysf~nction.~"
The patient's Dizziness Handicap Inv e n t o r y (DHI) score was 66. Scores range from
zero to 100. A score of zero indicates no symptoms.
The DHI measures perceived handicapping effects of
dizziness. A score of 66, in our experience, reflects
severe symptoms.
The patient had normal strength, sensation, and
deep tendon reflexes in all extremities. At baseline,
the patient's dizziness symptoms were 50/100 based
on a verbal analog scale (higher scores indicate
greater perceived dizziness). She related a mild increase in symptoms during head movements with her
eyes open and closed. Her dynamic posturography
score was normal for the Sensory Organization Test.
The patient's Dynamic Gait Index score was 20/24. A
score of 24/24 would be considered normal for her
age.m The therapist attempted to perform the DixHallpike maneuver in order to rule out BPPV, but
the patient was unable to tolerate the position because of nausea.
It was believed that the patient had symptoms consistent with cervicogenic dizziness based on her flexionextension injury, correlation of symptoms with
head movements and neck pain and the exclusion of
a peripheral vestibular diagnosis based on normal
performance on vestibular function testing (electronystagmography, caloric, positional and rotational
vestibular testing). Due to the patient's complaints of
dizziness, dysequilibrium, and her lack of confidence
in performing upright activities it was believed she
would benefit from a rehabilitation program that
would retrain her ability to use various balance strategies during functional activities. The patient was
provided with a home exercise program that emphasized walking, standing and performing head movements, rolling to the right and left, and standing
with eyes closed.
She was seen for 2 additional visits, 2 weeks apart.
During her fourth visit to physical therapy 2 months
after her initial evaluation, her ABC score had increased to 70% and her DHI had decreased to 40/
100. The patient was not complaining of any symp
toms at baseline and the DGI increased to 23/24.
However, she continued to have an increase in symp
toms while shopping and in busy visual environments. She had no symptoms while working. The patient was satisfied with the outcome of her therapy
and was discharged.
CONCLUSION
Cervicogenic dizziness is a diagnosis characterized
by dizziness and dysequilibrium that is associated
with neck pain in patients with cervical pathology.
The current literature on this topic is limited with
respect to the number and quality of the clinical uials reported. The diagnosis is dependent on correlating symptoms of imbalance and dizziness with neck
pain and excluding other vestibular disorders on the
basis of history, examination, and vestibular function
tests. When diagnosed correctly, we believe that cervicogenic dizziness can be successfully treated using a
J Orthop Sports Phys Ther-Volume SO. Number 12.December 2000
combination o f manual therapy and vestibular rehabilitation.
Manual therapy is recommended treatment for
cervicogenic dizziness directed at decreasing muscle
spasms and trigger points o f pain in the cervical
musculature. In the first case presented, although
the patient's neck pain and balance appeared to improve with manual therapy, i t was n o t until she was
also given vestibular rehabilitation exercises that the
symptoms o f dizziness improved. In the second case,
the patient improved with a home exercise program
that addressed cervical range o f motion and balance.
From o u r clinical experience, we recommend that
cervicogenic dizziness be treated with manual therapy t o decrease the irritation o n the cervical proprioceptors f r o m muscle spasms and trigger points, and
exercises with graded exposure t o sensory inputs to
improve the patient's use o f vestibular and proprioceptive inputs for balance. In addition, we recommend eye exercises to improve the function o f the
vestibular-ocular reflex. In order t o fully address all
o f the patient's symptoms, i t may be necessary for
the orthopaedic and vestibular specialists to treat the
patient together.
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