Ron Schenk PT, PhD, OCS, FAAOMPT, Cert. MDT
Laura B Coons, DPT
Susan E. Bennett PT, EdD, NCS
Peter A. Huijbregts, PT, DPT, OCS, FAAOMPT, FCAMT
Abstract: The diagnosis and treatment of patients with dizziness of a cervical origin may pose a challenge for orthopaedic and vestibular physical therapy specialists. A thorough examination, which consists of a screening examination to rule out pathologies not amenable to sole physical therapy management and, if indicated, a physical therapy differential diagnostic process incorporating both cervical spine and vestibular tests and measures, may indicate an appropriate course of management. The treatment progression is then based on patient signs, symptoms, and response to physical therapy interventions. This case study describes the diagnosis, treatment, and outcomes of a patient with cervicogenic dizziness co-managed by a vestibular and an orthopaedic manual physical therapist.
Key Words: Dizziness, Cervicogenic, Orthopaedic Manual Physical Therapy, Vestibular Physical Therapy
Patients complaining of dizziness often pose a diagnostic challenge because of the varied possible
eitiologies responsible for this symptom. Perhaps most relevant to the orthopaedic manual physical therapist is the fact that dizziness may be of cervical spine origin but this symptom may also occur as a result of vestibular, cardiovascular, neurological, metabolic, and psychiatric causes1. Because many conditions, both benign and serious, can cause dizziness, comprehensive differential diagnosis for a patient complaining of dizziness is not only difficult but also essential1. Huijbregts and Vidal1 recommended the consistent use of a classification system to assist in the differential diagnosis of dizziness. The authors referred to 4 subtypes for classifying complaints of dizziness: vertigo, presyncope, dysequilibrium, and other dizziness. Table 1 provides an overview of these four subtypes and relevant associated pathologies.
Cervicogenic dizziness is dizziness attributed to involvement of the cervical spine2,3. Biesinger2 and Wrisley et al3 suggested that the following symptoms are indicative of a diagnosis of cervicogenic dizziness that may respond to physical therapy (PT) interventions:
- Pain or discomfort in the cervical region, especially following trauma
- Dizziness that can be provoked by certain head positions or movements
- Dizziness of short duration and decreasing intensity
- Persistent occipital region headache
- Limited cervical spine range of motion (ROM)
- Jaw pain
- Upper extremity radicular symptoms
Three mechanisms have been implicated in the etiology of cervicogenic dizziness2,4:
- Irritation of the cervical sympathetic nervous system
- Mechanical compression or stenosis of the vertebral artery
- Involvement of the proprioceptors of the upper cervical spine caused by functional disorders in the segments C0-C3
The cervical sympathetic ganglia lie parallel to the spinal cord traversing along blood vessels and muscles antero-lateral to the vertebral bodies. The superior cervical ganglion, the largest of the cervical sympathetic ganglia and formed by coalescence of the cranial four sympathetic ganglia5, is located at the level of C2-C3. Upper cervical dysfunction has been hypothesized to negatively impact this ganglion2,4. This might affect the sympathetic innervations of both the vertebral and internal carotid arteries with subsequent posterior circulation hypoperfusion resulting in complaints of presyncopal dizziness5,6.
Mechanical compression, tension, dissection, or stenosis of one or both vertebral arteries as they pass through the cervical region will cause decreased blood flow and can also result in symptoms of presyncopal dizziness. Faulty head and neck posture, congenital deformities of the bones and tissues of the upper cervical spine, and traumatic or degenerative instabilities are among the causes of the mechanical compromise that could result in decreased vertebrobasilar blood flow1,2,4,7.
Relationships between neck proprioceptors of the upper and lower cervical spine dorsal roots and vestibular nuclei play a role in eye-hand coordination, perception of balance, and postural adjustments3. Dysequilibrium subtype dizziness of cervicogenic origin is hypothesized to result from abnormal afferent input to the vestibular nucleus from damaged joint receptors in the upper cervical region. Clinically, this might be suspected in patients with cervical spondylosis or after treatment with cervical traction and after trauma to the neck8. Cohen9 described deficits in balance, orientation, and coordination in primates following injection of anaesthetic in the upper three cervical dorsal roots. Wrisley et al3 hypothesized a role for irritation on the cervical proprioceptors from muscle spasms and trigger points in the etiology of cervicogenic dizziness. Postural asymmetries of the head and neck might create unequal compression and tension on the articulating surfaces of the first three vertebrae, ligaments, and muscles. Faulty posture and muscle imbalances might also cause decreased ROM and produce conflicting signals with regard to head position to the central nervous system (CNS) when it compares vestibular, visual, and cervical input. Both the deep cervical flexor muscles and the cervical joint capsules are lined with mechanoreceptors and are hypothesized to play a role in dizziness if dysfunctional3. Brown10 stated that with strong connections between the cervical proprioceptors and balance function, it is understandable that injury or pathology of the neck may be associated with a sense of dizziness or dysequilibrium.
Because all of these factors may contribute to cervicogenic dizziness, orthopaedic manual physical therapy (OMPT) intervention may include stability exercises, postural re-education, stretching of shortened muscles, strengthening of weak muscles, and improvement of cervical spine joint play2,3,10-12. In a systematic review of the literature, Reid and Rivett13 noted that all studies of manual therapy treatment of patients with cervicogenic dizziness reported consistent post-treatment decreases in symptoms and signs of dizziness. Vestibular rehabilitation is sometimes a necessary adjunct to the treatment of patients with dizziness of suspected cervical origin3. Several authors have reported successful outcomes when incorporating vestibular rehabilitation exercises with OMPT in the treatment of patients with cervicogenic dizziness2,3,12,14.
The literature on PT evaluation and management of patients with cervicogenic dizziness is limited. Cervicogenic dizziness is a diagnosis of exclusion: When dizziness related to other conditions has been ruled out, dizziness due to either hypomobility or instability of the upper cervical spine may be considered1. This clearly illustrates the need for a screening examination for conditions causing dizziness that are not amenable to sole PT management and that, therefore, require referral for medical-surgical (co)management. It also indicates the need for a PT differential diagnosis in order to determine both appropriate further tests and subsequent interventions. The purpose of this case report is to illustrate OMPT and vestibular physical therapy co-management of a patient complaining of dizziness of cervical origin.