Distinguishing features of Cervicogenic dizziness

When I started investigating the symptomology of dizziness, I hoped to find a clear distinction between descriptors and symptoms relating to each possible cause of dizziness. Dizziness however, is not that simple and symptoms aren't black and white. There is a lot of cross over between categories. Our confidence in clinical reason increases if we are able to tease out the finer details of what our patient's are experiencing. The purpose of this blog is to understand the distinguishing features of cervicogenic dizziness. 

My first questions to answer for this topic was: what are the distinguishing features of cervicogenic dizziness? Like me, you may respond to this question with dizziness which is provoked by movements of the neck. This is true, but this feature is not the distinguishing one. Brandt & Bronstein describe that “experiencing unsteadiness or vertigo associated with neck movements could be due to a disorder in vestibular, visual, vascular, neurovascular, or cervicoproprioceptive mechanisms” (2001, p. 8).

Coming to understand this point made it clear that delineating symptoms to each category was going to be challenging and instead we may need to look for a cluster of symptoms to guide our reasoning. It also became clear that we need to be careful with the terms we use to describe dizziness. One misguiding term that I came across a lot in the literature is cervical vertigo. Cervical vertigo is often used to describe cervicogenic dizziness but should not be mistaken for true vertigo. Vertigo is a result of vestibular pathology.

Comparatively, cervicogenic dizziness is a more vague symptom of unsteadiness and imbalance. These symptoms last for minutes to hours and should have a temporal relationship to neck pain and a mechanical relationship to neck movements (Schenk, Coons, Bennett, & Huijbregts, 2006; Treleaven, et al., 2003).  It is hypothesised that cervicogenic dizziness is caused by abnormal afferent activity from the neck. The sensory mismatch theory states that inaccurate cervical mechanoreceptor information on head position may contradict afferent input from the visual and vestibular systems, therefore giving rise to dizziness and unsteadiness (Brandt & Bronstein, 2001; Kristjansson & Treleaven, 2009). 

Vertigo is described as the sensation of the environment or self-­spinning, it is only temporary and made worse by head movements. Patients with vertigo don’t continue to move around while episodes are occurring (Halmagyi & Halmagyi, 2000). So if the patient has continuous dizziness or isn’t perturbed to continue moving while feeling dizzy, then they most likely don’t have vertigo. Vertigo is a result of vestibular pathology which can be caused by central and peripheral pathology. Conditions often discussed in association with vertigo are Benign Paroxysmal Positional Vertigo (BPPV), Menier’s disease, vestibular neuritis, migrainous vertigo, and vestibular neuropathy.

The first step to understanding dizziness is to get specific with your subjective assessment. You should always follow the same format for a subject assessment and when it comes to dizziness, don't forget to ask about family medical history, general health, medication use and question for red flags. These reasons for this will become apparent in the next post when we explore other medical causes of dizziness. 

Interviewing the patient

These are some specific questions you can ask your patient about their dizziness (Appendix 1, Treleaven, et al., 2003):

1. What words best describe your dizziness/unsteadiness?
2. How often do you get these symptoms?
3. How long do they last?
4. What brings on these symptoms?
5. When you experience these symptoms what do you do?
6. Have you fallen or lost balance when these symptoms occur?
7. Is there anything else that occurs at the same time?
8. How soon after the accident did these symptoms occur?

Responses might be....

What words best describe your dizziness/unsteadiness?

1. Vestibular - imbalance in the dark, vision moving, dislike things moving past me fast, eyes jiggling, motion sick, must focus when walking, tilting, imbalance on soft surface. 
2. Vertigo - room spinning or you're spinning. 
3. Cardiac - might fall, falling, faintness, trouble with stairs.
4. Central nervous system - falling, veering to one side, clumsy.
5. Cervicogenic - vague imbalance, light headedness, floating, unsteady, clumsy. 
6. Others -giddy, sea legs, swimming, dissociated from body, floating, off-­balance, drunkenness, fogginess, cloudiness, not secure, like steeping off an elevator.

How often do you get these symptoms? All the time – constant or varying? Several times a day or once a day/week/fortnight etc. 

How long to they last? Seconds, minutes, hours.

What brings on these symptoms?

1. Vestibular- rolling over in bed, lying on side, moving quickly, walking in busy places, lying down. 
2. Cervicogenic - moving head quickly, increased neck pain, certain neck positions, headache, sitting and standing up, 
3. Cardiac -  sitting up, stranding up, coughing, sneezing, stress, certain neck positions (if VBI).
4. Psychiatric - if anxious, walking in busy places, stress. 

When you experience these symptoms what do you do?

Keep going, slow down, breathe slowly and deeply, change head position, hold onto something, stand still, change position of body, stop and sit/lie down. We know that patients with vertigo don't push through, they stop, change position and wait for symptoms to settle. Cervicogenic dizziness might change neck position, might change environment (visual input) and those with anxiety or a psychological condition might try relaxation techniques. 

Have you fallen or lost balance when these symptoms occur?

1. NO (Those with cervicogenic dizziness don't often fall over. This is more a symptom of central nervous system disease or cardiac disease i.e are they tripping or are their fainting?). 
2. Yes – how often?

Is there anything else that occurs at the same time?

1. VBI - blurred vision, double vision, difficulty speaking, difficulty swallowing, drop attack, nausea, vomitting.... 5D's and 3N's. 
2. Vestibular - ringing in ears, hearing loss,  nausea, vomitting, oscillopsia (the illusion that stationary objects are moving during/after head movements), and falling to one side.
3. Cardiac - tight chest, shortness of breathe.
4. Cervicogenic  - headache, decreased concentration, blurred vision, and nausea. 
5. Other symptoms: lump in throat, pins and needles, sweating, decreased concentration, pallor. 

How soon after the accident did the symptoms occur? Immediately, within 24 hours, within one week, within one month, after one month.

SOME CLARIFYING QUESTIONS:

1. Did you feel like you were going to pass out or fall over?
2. Did you feel like the room was spinning or you were unsteady?
3. Did you loose your balance or loose consciousness?
4. When it happens do you lie down or keep moving?
5. Does the dizziness start spontaneously or when your move your head or when you roll over in bed?

A cluster of symptoms for cervicogenic dizziness

Treleaven, et al. (2003) found that in whiplash associated disorders:

• The most common descriptions of dizziness were light-­headedness, unsteadiness, unbalanced and feeling clumsy.
• The most common exacerbating features were increased neck pain, sitting and standing up, and neck movements.
• The most commonly associated symptoms were headache, nausea, blurred vision and decreased concentration.
• WAD is one condition in which patients complain of cervicogenic dizziness and therefore the results of this study can be used to help define the distinguishing features of this condition. 
• Participants in the studies mentioned above did not indicate high levels of symptoms more commonly associated with vestibular disorders, anxiety, or medication‐induced dizziness (Treleaven, et al., 2004; Treleaven, et al., 2005; Treleaven, et al., 2003).

Physical examination

Diagnosis of cervicogenic dizziness is one of exclusion. This is due to the lack of a gold standard assessment for this condition (Reid & Rivett, 2005). Therefore a thorough physical examination is required (some of which might not be completed by the physiotherapist). Other medical practitioners which can become involved in the assessment are a Neurologist, a GP (bloods, blood pressure, medication use, other medical health conditions), an Optometrist and Audiologist. 

What does the physiotherapist assess?

1. Cervical Spine - active and passive range of movement, manual palpation, muscle length, postural control, deep cervical neck flexor strength, neurological assessment (reflexes, muscle testing, sensation testing and maybe coordination and ataxia) and sensorimotor function. 
2. The assessment of sensorimotor function needs to involve the following features:
   1. Oculomotor assessment
   2. Optokinetic system 
   3. Balance test.

oculomotor assessment

Oculomotor assessment involves assessment of all aspects of eye movement. You will need to assess gaze stability while the head is moving, eye movement control i.e. smooth pursuit while the head is still, and head‐eye coordination during combined head and eye movement. Abnormal test results include difficultly or inability to complete the task, reproduction of symptoms (dizziness), or jerky/poorly controlled movements of the neck (Treleaven, et al., 2004).

1. Gaze Stability

Gaze stability is controlled by two reflexes, the VOR and the COR. The cervical component of gaze stability comes from the cervico-ocular reflex (COR). This is assessed in sitting with the patient instructed to try keep their gaze fixed on an object/point and move the head into flexion, extension and rotation. “For patients with marked symptoms, it may be necessary for the clinician to move the head passively, with the patient in supine lying. Pertinent findings are an inability to maintain focus on the target or reproduction of symptoms such as dizziness, blurring of vision, or nausea” (Sterling, et al., 2008, p. 180). Please note that this test is not the head-thrust test. 

The vestibular component of gaze stability comes from the vestibulo-ocular reflex (VOR). This is assessed with the head-thrust test (HTT). The VOR acts to keep images stable on the retina of the eye during head movement. The HTT is performed in sitting. The patient is instructed to keep their gaze fixed on an object (usually the therapist' nose) while the therapist passively moves the head in small and rapid rotation movements which are in an unpredictable direction. The test is considered positive if the patient cannot maintain gaze fixation and corrective saccades are used to return the eyes to the target (Schubert & Minor, 2004). The HTT is reported to have 71% sensitivity and 84% specificity for detecting unilateral vestibular hypofunction, and 84% sensitivity and 69% specificity for bilateral vestibular hypofunction (Schubert, Tusa, Grine, & Herdman, 2004). 

2. Smooth pursuit

Smooth pursuit neck torsion test is used to assess the proprioceptive reflexes in the neck, mainly the CCR and VCR in relation to neck movements (Treleaven, et al., 2004). Smooth eye movement is performed by observing eye movement control while following an object. It is assessed in neutral and again with trunk rotation of 45 degrees. The trunk rotation stimulates mechanoreceptors in neck muscles without affecting the vestibular system and can therefore differentiate from vestibular pathology, brain stem injury and other central nervous system dysfunctions (Brandt & Bronstein, 2001). The SPNT test has been reported as a sensitivity of 72% and specificity of 90% in the diagnosis of WAD (Treleaven, et al., 2004, p. 219). The therapist may also observe saccadic movements (where the eyes rapidly move horizontally as they try to focus on an object). If this occurs more in the rotated position then the cervical spine can be implicated. 

Experimentally smooth pursuit of eye movement is evaluated with electrooculography while the eyes follow a lazer pointer with the neck in neutral and then with the trunk rotated to 45 degrees in each direction, while the neck and head remains still.

Clinically, smooth pursuit neck torsion test is performed to measure the ability of the eyes to follow a slow moving target while the neck mechanoreceptors are placed under varying degrees often stretch. The target (usually focussing on the tip of a pen) is moved up/down and from side to side while assessing the ability of the eyes to follow smoothly without jerky movements or reproduction of symptoms. The test is then repeated with the trunk in 45 degrees of rotation.

Position 1: Trunk straight, head straight, eyes following pen.

Phase 2: Trunk turned 45 deg & eyes following pen.

3. Head-eye coordination

"Eye–head coordination is assessed with three tests. Firstly the patient is asked to move the eyes and head in the same direction to focus on a target, leading first with the eyes to the target and then the head, ensuring the eyes keep focused on the target. The test is performed to the left and right. Secondly the patient is asked to move the eyes and the head in opposite directions while maintaining focus on a predetermined point. Finally, the patient is asked to focus on two points and move the eyes first and then the head, to look between the two targets. The target points are positioned horizontally or vertically and the patient maintains focus between the two points (two-point focus)" (Sterling, et al., 2008, p. 180-181). 

JPET courtesy of Physiopedia

OPTOKINETIC ASSESSMENT

Joint position error test is thought to be a reflection of neck reposition sense as it measures the afferent input from cervical joint and muscle receptors and often used in assessment of cervicogenic dizziness. “The measure of cervical joint position error tests a patient’s ability to relocate the position of the head to a natural head posture or to a predetermined target whilst vision is occluded” (Sterling, et al., 2008, p. 76). Normal joint position sense or “straight ahead” positioning is heavily reliant on the muscles controlling the position of the cervical spine (Brandt & Bronstein, 2001). Brandt and Bronstein (2001, p. 9) describe that the role of cervical afferents is more important in “the generation of automatic reflexes but less important for generating conscious perceptions of head turning”.

In the research environment joint position error can be assessed with non-­invasive electromagnetic devices such as the Fastrak. This measures the degree of error from the starting position of the head to the return position following three directions of movement – left rotation, right rotation and extension.

In the clinical setting however, where such devices aren't accessible, it is still possible to measure joint position error. Although you can rely on visual observation of the difference in end position compared to starting position, errors of 3­‐4 degrees are considered significant in joint position error but may be too difficult to visually detect. Therefore other tools which are available include laser pointers, which attach around the head with a circular band.

Performing the test: The patient is positioned 90cm away from the wall and the measurement of the end position compared to the starting position is taken in cm either –ve or +ve to indicate over and under shooting. Other descriptors may include any reproduction of dizziness, a jerky movement, or a large discrepancy in joint position error when comparing eyes open to eyes closed. For further details on testing procedure you may choose to refer to Sterling, et al. (2008) chapter 12 which covers the entire physiotherapy assessment for the cervical spine (a great reference point for every test).

Balance assessment

Balance assessments are tests we are more familiar with from training in neurological physiotherapy. For static balance assessment the BESS is a great measure. There are several levels of the assessment: feet apart, feet together, tandem stance, and single leg stance, with each being performed in eyes open, eyes closed and on foam. For dynamic balance, tests such as the timed up and go, 10m walk test, and dynamic gait index are easily completed in the clinical setting and provide valid and reliable measures of postural balance (Sterling, et al., 2008).

For further reference click on the link to review the balance error scoring system (BESS). In the BESS a score is allocated for each component based on the number of errors – eyes opening, moving arms and touching ground with feet. 

Alternatively you can just assess static balance and postural sway using the Rhombergs test, which is considered positive if any of these errors occur within the first 30 seconds. The patient stands with feet together, arms by their side or crossed and is asked to balance with eyes open and then eyes closed. 

Outcome measures for cervicogenic dizziness.

As previously mentioned, cervicogenic dizziness is a non-­specific symptom which is a result of sensorimotor dysfunction and there is no gold standard assessment and no specific outcome measures. This doesn't mean you can't use outcome measures, but aim to use validated tools to focussing on dizziness, neck pain and disability. This can be useful to gather information about symptoms and to evaluate change across treatment sessions. For example, Trevelean et al (2003) used the outcome measures to compare symptom severity to physical impairments and measure the correlation between the amount of dizziness and degree of joint position sense error. 

Outcome measures which may be clinically useful are (click on the link for the full document): 

• Dizziness handicap inventory
• Neck disability index
• State train anxiety inventory 
• Northwick Park Neck Pain Questionnaire. This is a neck pain and disability question developed in England. When compared to the Neck disability index, the Neck pain questionnaire examines physical, emotional and social aspects of disability, and therefore is used in assessment of Whiplash because it provides a greater variety of assessment of problems which can be present. 

In summary, cervicogenic dizziness although a diagnosis of exclusion is distinguishable from VBI and vertigo through a combination of symptoms and physical impairments. Physiotherapists are capable of making this diagnosis in the clinical setting and are able to determine when further medical evaluation is required. Cervicogenic dizziness is the one condition that displays deficits in sensorimotor dysfunction and the assessment outlined above helps us to understand what additional tests must be conducted to determine that the cervical spine is in fact, the cause of the problem. 

Now lets look at some other causes of dizziness....

Sian

REFERENCES:

Brandt, T., & Bronstein, A. M. (2001). NOSOLOGICAL ENTITIES?: Cervical vertigo. Journal of neurology, neurosurgery and psychiatry, 71(1), 8‐12.

Cherchi, M. (2011). Infrequent causes of disequilibrium in the adult. Otolaryngologic clinics of North America, 44(2), 405­‐414, ix.

Dispenza, F., De Stefano, A., Mathur, N., Croce, A., & Gallina, S. (2011). Benign paroxysmal positional vertigo following whiplash injury: a myth or a reality? American journal of otolaryngology, 32(5), 376-­380.

Halmagyi, G. M., & Halmagyi. (2000). Assessment and treatment of dizziness. Journal of neurology, neurosurgery and psychiatry, 68(2), 129‐134.

Moubayed, S. P., & Saliba, I. (2009). Vertebrobasilar insufficiency presenting as isolated positional vertigo or dizziness: A double‐blind retrospective cohort study. The Laryngoscope, 119(10), 2071-­2076.

Reid, S. A., & Rivett, D. A. (2005). Manual therapy treatment of cervicogenic dizziness: a systematic review. Manual Therapy, 10(1), 4-13.

Schenk, R., Coons, L. B., Bennett, S. E., & Huijbregts, P. A. (2006). Cervicogenic dizziness: A case report illustrating orthopaedic manual and vestibular physical therapy comanagement. The Journal of manual & manipulative therapy, 14(3), E56‐E68.

Schubert, M. C., & Minor, L. B. (2004). Vestibulo-ocular physiology underlying vestibular hypofunction. Physical Therapy, 84(4), 373-385.

Schubert, M. C., Tusa, R. J., Grine, L. E., & Herdman, S. J. (2004). Optimizing the sensitivity of the head thrust test for identifying vestibular hypofunction. Physical Therapy, 84(2), 151-158.

Sjaastad, O., & Bakketeig, L. S. (2008). Prevalence of cervicogenic headache: Vaga study of headache epidemiology.Acta neurologica Scandinavica, 117(3), 173-180.

Sterling, M., Falla, D., Jull, G., Treleaven, J., & O'Leary, S. (2008). Whiplash, headache, and neck pain: research-­based directions for physical therapies: Elsevier Health Sciences.

Susanto, M. (2014). Dizziness: if not vertigo could it be cardiac disease? Australian family physician, 43(5), 264.

Treleaven, J., Clamaron Cheers, C., & Jull, G. (2011). Does the region of pain influence the presence of sensorimotor disturbances in neck pain disorders? Manual therapy, 16(6), 636-­640.

Treleaven, J., Jull, G., & Low Choy, N. (2004). Smooth pursuit neck torsion test in whiplash-­‐associated disorders: relationship to self-­‐reports of neck pain and disability, dizziness and anxiety. Journal of rehabilitation medicine, 37(4), 1‐1.

Treleaven, J., Jull, G., & Low Choy, N. (2005). Standing balance in persistent whiplash: a comparison between subjects with and without dizziness. Journal of rehabilitation medicine, 37(4), 224-­229.

Treleaven, J., Jull, G., & Sterling, M. (2003). Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error. Journal of rehabilitation medicine, 35(1), 36‐43. 

Treleaven, J., LowChoy, N., Darnell, R., Panizza, B., Brown-Rothwell, D., & Jull, G. (2008). Comparison of sensorimotor disturbance between subjects with persistent whiplash-associated disorder and subjects with vestibular pathology associated with acoustic neuroma. Archives of Physical Medicine and Rehabilitation, 89(3), 522-530.