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Cervicogenic Dizziness - identification and treatment

Dr. Sue Reid

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Cervicogenic Dizziness - identification and treatment

  1. 1. Cervicogenic Dizziness: identification and treatment Sue Reid (PhD, MMedScPhty, GradDipManipTher, BAppSC(Phty), BPharm)
  2. 2. Dizziness • Dizziness is a common problem: 200 mill visits annually (Newman- Toker 2012) • Many types of dizziness and causes • Diagnosis challenging: 50% misdiagnosed (Newman-Toker 2012) • Cost to diagnose: $2,500 per patient
  3. 3. Traditionally divided according to quality-of-symptoms (Drachman & Hart 1972) Symptom Possible cause Imbalance, unsteadiness Cervicogenic dizziness, musculoskeletal disorders, vestibular problems Near syncope (faint), light-headedness Cardiovascular causes Confusion, anxiety Psychogenic dizziness Vertigo Peripheral vestibular, Central nervous system
  4. 4. Vertigo • A sensation of movement • Rotatory or spinning • Nausea/ vomiting • The most common type of dizziness (Hain 2004) • Caused by central nervous system or peripheral vestibular disorders
  5. 5. Descriptions of dizziness • Descriptions of dizziness: vague, unclear, inconsistent and unreliable • 62% (n=872) selected more than one type of dizziness (Newman-Toker et al 2007) • 52% picked a different response on retest 6 minutes later (Newman-Toker et al 2007) • More reliable: behaviour of dizziness e.g. duration, triggers and associated symptoms
  6. 6. Cervicogenic dizziness Dizziness described as imbalance or disequilibrium Provoked by head movements or positions Associated with neck pain or stiffness
  7. 7. Vestibular Nuclei Vestibular system Visual system Proprioceptors of the cervical joints and muscles (Cronin 1997, Furman & Whitney 2000) Inputs to the vestibular nuclei that maintain balance
  8. 8. Cause of cervicogenic dizziness? Dysfunction of upper cervical joint receptors or deep cervical muscles (Brandt 1991, Reid et al 2008, Wrisley et al 2000) Result of a perturbation in the information from sensory afferents in the cervical spine (Brandt & Bronstein 2001)
  9. 9. Identification of cervicogenic dizziness • No diagnostic test, hence controversial diagnosis • Five step process developed • Shown to be successful as previous studies using this identified people with CD and then they were successfully treated (Reid et al 2008, 2014, 2015) • Can be used clinically to identify people and offer appropriate treatment
  10. 10. Diagnostic process for cervicogenic dizziness 1) Type of dizziness 2) Eliminate other causes for dizziness or unsteadiness 3) Neck pain and/or stiffness 4) Provocation by cervical movements 5) Physical tests: ROM, cervical signs on palpation, balance, Dix-Hallpike test
  11. 11. 1. Dizziness characteristics • Must be consistent with cervicogenic dizziness • UNSTEADINESS imbalance, disequilibrium • Exclude other types of dizziness – vertigo, presyncope, anxiety • Ask about dizziness behaviour: onset, severity, frequency, duration
  12. 12. 2. Elimination of other causes of dizziness or unsteadiness • Ask about stroke, spinal cord pathology, cerebellar ataxia, Parkinson’s disease
  13. 13. 3. Presence of neck pain or stiffness • Neck pain, discomfort, neck stiffness, occipital pain and/or headache (Malmstrom et al 2009) • Less common: TMJ pain (Malmstom et al 2009), radiculopathy (Schenk et al 2006; Wrisley et al 2000,) ear fullness, blurred vision, sweating, tinnitus, problems with swallowing, • History of pain behaviour: onset, duration, frequency, aggravating and easing factors
  14. 14. 4. Provocation of dizziness by neck movements • The unsteadiness or poor balance must be exacerbated by cervical movements or positions • Usually extension, or rotation (Mulligan 1999, Reid et al 2008)
  15. 15. 5. Physical examination • Cervical ROM • Palpation of soft tissues (upper cervical spine) • Passive accessory intervertebral movements: PA and unilateral PA pressures (occiput to C3) • Balance • Smooth pursuit neck torsion test • Dix-Hallpike manoeuvre to identify BPPV
  16. 16. Identification of cervicogenic dizziness Patients treated with manual therapy had decreased dizziness and pain after 2-4 treatments with Mulligan SNAGs (Reid et al 2008, 2014, 2015 ) Prompt favourable response to manual therapy treatment helps identify this condition
  17. 17. Differential diagnosis of cervicogenic dizziness • Benign Paroxysmal Positional Vertigo (BPPV) • VBI (including VA dissection) • Migraine • Cardiovascular dizziness
  18. 18. Benign paroxysmal positional vertigo (BPPV) • Brief, intense, severe rotational vertigo • The most common causes of vertigo (20-30%) • Precipitated by changes in head position, rolling • Usually resolves spontaneously (weeks /mths) (Brandt & Daroff 1980)
  19. 19. BPPV • Debris from utricle (otoconia: crystals of Ca Carb) goes into canal • Usually posterior semicircular canal (Parnes et al. 2003)
  20. 20. Dix-Hallpike manoeuvre Head turned 45 degrees to the right (Bronstein 2003) Patient taken quickly into supine head-hanging
  21. 21. BPPV (canalithiasis) Nystagmus Rotational/torsional High frequency Up-beating Latent (2-15 secs) Dissipates in <60 sec Fatigues Reverses on sitting
  22. 22. Treatment of BPPV Particle re-positioning manoeuvres Parnes, L. S. et al. (2003). CMAJ,169:681-693 Aim to float the particles into the vestibule (if canalithliasis) •Epley manoeuvre: -Immediate relief in 50-80% of cases (Hain 2004). -70-90%response 1-3 sessions •Semont’s manoeuvre •Brandt Daroff exs: 98% response in 3-14 days
  23. 23. Manual therapy treatment of cervicogenic dizziness Useful treatments; • Maitland Passive Joint Mobilisations • Mulligan Sustained Natural Apophyseal Glides (SNAGs) • Exercises
  24. 24. Sustained natural apophyseal glides (SNAGs) are an effective treatment for cervicogenic dizziness Susan A. Reid, Darren A. Rivett, Michael G. Katekar, Robin Callister Manual Therapy 13 (2008) 357–366 STUDY 1 • RCT compared Mulligan SNAGs to placebo • Showed decreased dizziness, pain, disability with 4 treatments of SNAGs. • Effect maintained 12 weeks • Limitations: no longer term follow-up, no home treatment
  25. 25. Dizziness• STUDY 2 RCT (2014, 2015) • SNAGs plus self-SNAGs • Maitland passive joint mobilizations (MM) plus range of motion exercises • Placebo • 12 month follow-up • For dizziness intensity, frequency and the DHI SNAG and MM groups better than placebo Intensity DHI Frequency
  26. 26. Extension • Ext: Significant increase post treatment in the SNAG group but not MM or placebo. Effect maintained for 12 mths • SNAG group was better than MM post treatment and at 12 wks. • For ext and flex SNAG was better than placebo at all time points, while MM was not better at any time. STUDY 2 Results ROM
  27. 27. SNAG treatment (Mulligan 1999) Used physiological movement or position causing dizziness Extension (most common) flexion: • Anterior glide to C2 spinous process • Patient extends • Overpressure added by patient at end of range • Repeated six times • Treatment is symptom-free Self-SNAG
  28. 28. Self- SNAG for extension Home treatment of self-SNAG into ipsilateral rotation (x6) once a day
  29. 29. SNAG for rotation SNAG • Anterior glide to ipsilateral C1 transverse process • (If no relief, glide contralateral process) • Patient performs rotation • Overpressure added by patient at end of range • Repeated six times • Treatment is symptom-free
  30. 30. Self- SNAG for rotation Home treatment of self-SNAG into ipsilateral rotation (x6) once a day
  31. 31. Maitland passive joint mobilisations (MM) Central PA pressure Unilateral PA pressure
  32. 32. Maitland passive joint mobilisations • Used to treat cervical pain and decreased ROM (Miller 2010) • Mainstream physiotherapy practice • Moderate evidence for positive effect on pain, function and patient satisfaction at intermediate-term follow-up (Gross et al, 2010)
  33. 33. Multi-modal treatment of cervicogenic dizziness Treat sensorimotor impairments: • i) Balance eg tandem balance (eyes open and closed) • ii) Occulo-motor impairments eg eye follow, gaze stability exercises, eye and head co-ordination exercises. • iii) Cervical joint position error
  34. 34. Patient: 76 year old kayaker •World long distance kayak record; 50km 3/wk •Turn to right fell out of kayak •30 years stiff, painful neck •Post treatment “fantastic” only occasional dizziness, returned to sport TK1 Mr N results 0 10 20 30 40 50 60 70 80 90 1 2 3 4 TimelineScores Dizziness DHI Pain
  35. 35. In conclusion • Be informed about the signs and symptoms of these conditions to identify the cause of the dizziness • Make a risk assessment prior to manual therapy treatment • If concerned use gentle pain free treatment techniques
  36. 36. References • Reid SA & Rivett DA. (2005) Manual therapy treatment of cervicogenic dizziness: a systematic review. Manual Therapy, 10:4-13. • Reid SA, Rivett DA, Katekar MG & Callister R. (2008) Sustained natural apophyseal glides (SNAGs) are an effective treatment for cervicogenic dizziness. Manual Therapy, 13:357–366. • Reid SA, Rivett DA, Katekar MG & Callister R. (2012) Efficacy of manual therapy treatments for people with cervicogenic dizziness and pain: protocol of a randomised controlled trial. BMC Musculoskeletal Disorders, 13:201-208. • Reid SA, Rivett DA, Katekar M & Callister R. (2014) Comparison of Mulligan Sustained Natural Apophyseal Glides and Maitland Mobilizations for Treatment of Cervicogenic Dizziness: a Randomized Controlled Trial. Physical Therapy, 94:466-476. • Reid SA, Rivett DA, Katekar M & Callister R. (2014) The Effects of Cervical Spine Manual Therapy on Cervical Range of Motion, Head Repositioning and Balance in Participants with Cervicogenic Dizziness: A Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation, 95:1603-12. • Reid SA, Callister R, Snodgrass SG, Katekar MG & Rivett RA. (2015) Manual therapy treatment of cervicogenic dizziness: long-term outcomes of a randomised controlled trial. Manual Therapy, 20:148-156.
  37. 37. Acknowledgements • Australian Catholic University (ACU) • The University of Newcastle (UoN) • Prof Darren Rivett (UoN) • Lucy Thomas (UoN) • Prof Robin Callister (UoN) • Dr Michael Katekar, Neurologist Newcastle • Mulligan Concept Teachers Association Research Grant

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