“…characterized by the presence of imbalance, unsteadiness, disorientation, neck pain, limited cervical range of motion, and may be accompanied by a headache.”
Dizziness can have multiple factors. The cervical spine, or neck region, can have a role in a person feeling unsteady or dizzy.
“…when all other causes of dizziness are excluded”
Before making a jump to the cervical spine, the professional performing the evaluation/examination should rule out red flags. Some of these include an active stroke, instability of the neck region after a major trauma, a severing or tear in an artery that supplies the brain.
Other causes of dizziness are BPPV (Benign Paroxysmal Positional Vertigo), vestibular hypofunction, Ménière’s disease, issues affecting the inner ear such as a fistula and many other conditions. Click here to learn more about vestibular issues and dizziness.
“… dizziness should be closely related to changes in cervical spine position or cervical joint movement”
In order to state that the dizziness is coming from the neck, movements of the neck should create a change in symptoms.
It seems like common sense, but I’ll never state that common sense is in abundance in healthcare.
It’s like a person comes in complaining of shoulder and arm pain when looking down, which goes away when looking up, but the clinician spends all of the allotted time moving the shoulder and arm 🤦🏻♀️
“diagnosis of exclusion”
This is important. In order to get to this as the cause of the patient’s symptoms, the clinician has to rule out red flags (really bad stuff), BPPV (fast changing symptoms), vestibular dysfunctions (slow changing), brain issues (really slow changing) and then finally get to the neck.
The reason this is called a diagnosis of exclusion is this: when a person is thorough all of the possibilities have been ruled out. This is all that’s left.
“…no single test is able to diagnose the condition, and the diagnosis can not be verified by outcomes, imaging, laboratory values, or unique signs and/or symptoms”
This is important. If there are no tests to determine that this is the problem, it truly is a last resort to treat. We are hoping that this is the cause, and it takes a hard sell job to get the patient on board for treatment of this problem.
“…a systematic process is a pragmatic tool for differential diagnosis of CGD…with utilization of a rule out, rule in paradigm”
This is important. The rule in/rule out paradigm is another way of sayin whiteboarding, at least in my head.
This not so short video series speaks to performing differential diagnosing. Although as a PT, I am not allowed to issue a medical diagnosis, we have to be able to perform differentials and I’ll explain why.
When a physician refers a patient to PT for these issues, many times the diagnosis code given is “dizziness and giddiness”, “frequent falls”, or generalized weakness. No offense to any physician, but this doesn’t tell me what’s wrong with the patient.
In defense of the physician, they may not be trained to perform the testing required in order to determine what is the underlying, or root cause, of the dizziness. Also, on average physicians don’t get to spend the allowed time with the patient in order to perform these tests. I surely can’t treat something if I don’t have an idea of what is wrong. There must be some clue telling me where to start, and this is the power of doing a differential in order to classify what is the major problem and what may be the lesser problems causing a person to be dizzy or off balance.
Because there is not just one cause, there can not be just one treatment.
Hope this makes sense.
“CGD should not be considered if the patient does not have neck pain…neck pain can occur at rest, with movement or with palpation”
It only makes sense that if we believe that there is a problem in the neck that is causing a major disruption in that persons ability to function that we should also be able to find a problem in the neck if we try hard enough.
Pain is so elusive that it may not present in a typical manner. I have patients that only have neck pain provoked at their end-range, which is limited. This would fit the category.
“Vertigo as an illusion of movement;a sensation as if the external world were revolving around the individual (objective vertigo), or as if the individual were revolving in space (subjective vertigo). Vertigo is not a symptom arising from cervical spine, but rather is caused by peripheral vestibular disorders or lesions within the vestibular pathways of the central nervous system”
This is where things become fun. It reminds me of taking my daughter to a fun house. First, getting into the house was hilarious. It started as a house of mirrors. I can’t believe how many times she hit her face into the mirror because she thought it was the exit. The first time she hit her face on the mirror, I was a concerned dad and tried to offer help. By the time she hit her face on the mirror the third time I couldn’t constrain myself any longer. Because it was a house of mirrors she saw me laughing…1,000 mirrored reflections laughing.
I digress.
To get out of the fun house, we had to cross a bridge that had a tunnel spinning around it, which gave the illusion that we were moving. If one closed the eyes and walked, it was easy. If one kept the eyes opened it was a scene out of a sinking ship. My daughter was holding onto the rails for dear life…even though nothing she was standing on or touching was moving.
Vertigo is something like that 😂.
“The duration of symptoms for CGD can range from days to months to years”
This is where I start to have some issues.
A classification of dizziness that we can’t prove, have no great testing to show us that it is happening can have a duration of a short period of time to a long period of time.
Holy specific Batman! This is why, as healthcare professionals, we can struggle at time. The research doesn’t give us concrete information that is useful when in front of the patient.
Patient: how long can this last
Doctor: 🤷♂️ months to years
Patient: how long do you think it will last for me
Doctor: (silence)
“Ménière’s disease is a chronic vestibular disorder characterized by episodic bouts of aural fullness, vertigo, and hearing loss. Cervicogenic dizziness however, typically does not include aural fullness, tinnitus or hearing loss”
What in the world is aural fullness?
This is a full feeling within the ear. Think of feeling pressure or a buildup of within the ear. In Ménière’s disease, this feeling comes and goes. The sensation may be accompanied by spinning sensations and hearing loss.
If the patient is experiencing hearing loss, then we can state that the cervical spine is not having a role in this symptom and additional testing of the vestibular, or balance gauge, system needs to be checked to ensure that nothing was missed.
As Johnnie Cochran has become famous for saying:
“If it doesn’t fit, you must acquit”
Some reading this may not be old enough to u see stand this phrase, but the meaning is that if part of the evidence presented doesn’t fit the case then there must be a different perspective followed.
This means that if you are experiencing dizziness that stems from the neck, you shouldn’t also experience hearing loss. If your provider is not listening to your symptoms, you may be wasting both time and money by undergoing treatment for the wrong classification.
“BPPV is the most common vestibular pathology… crystals become dislodged from the utricle and migrate into one of the three semicircular canals located within the inner ear.”
Benign (not harmful) Paroxysmal (sudden occurrence or intensification of symptoms) Positional (relating to the position of the body against gravity) Vertigo (illusion of movement when no movement is occurring) (BPPV) is very common to experience in one’s lifetime. About 3 out of every hundred will experience this. Although it doesn’t come close to the statistics for back pain, it is the most likely reason for experiencing vertigo.
The bad news: it really sucks to have this happen because any activity becomes difficult when you are experiencing your world spinning.
The good news: it’s treatable in a high percentage of cases with very few visits.
“if a patient has symptoms of vertigo accompanied by nystagmus in response to changing head position in space, then BPPV is more likely than CGD”
The nystagmus is the quick movement of the eyes. If we see a nystagmus (it is visible to the clinician) when moving patients through different positions, this helps to clarify not only that the patient has a positional dizziness, but also where the problem is located based on the position and the movement of the eyes.
For instance, if the patient has symptoms during a Dix-Hallpike, we can assume posterior canal, we then have to know if it is the left side or right sided canal in order to understand the proper direction of treatment.
If the patient has a positive Roll test, then this would implicate the horizontal canal, but again we would have to understand the side of dysfunction.
“… symptom duration lasting only a few seconds were significantly more common in the BPPV group. Cervical neck movement, fatigue, anxiety, and stress were also found to be more common precipitating factors for exacerbation of symptoms in the CGD group as compared to the BPPV group”
BPPV has short lasting symptoms. Once the crystals settle, then the symptoms subside.
The other symptoms of anxiety and stress do not tend to be causative factors in BPPV.
“…acute, unilateral, peripheral vestibular loss due to labrythitis or vestibular neuronitis…marked vertigo, imbalance…nausea and possibly vomiting…spontaneous horizontal, direction fixed nystagmus in room light”
When we see an acute peripheral vestibular loss it’s pretty cool, at least for me, as the eyes are all over the place. Because the eyes have difficulty focusing, the patient will see objects blurred or moving. This can create an imbalance and the movement seen, paired with the lack of actual movement of the body, can create a nausea feeling.
Although it is fun to work with, it is never fun to be vomited 🤮 on. My first year, I had no clue what I was doing and got a lot of vomit on my shoes.
“Key symptoms frequently present in vestibular migraine, but not CGD, are aura, true vertigo , throbbing headaches, sensitivity to auditory or visual sensory stimulation, and oculomotor changes”
If you’ve ever had a migraine, these can be debilitating. The sensitivity to light and sound are the two symptoms I hear the most, along with nausea. Cervicogenic dizziness should not present with the auditory or visual issues as these are controlled by cranial nerves (think brain nerves) and not neck nerves.
“Cervical arterial dysfunction (CAD) and whiplash associated disorders (WAD) are non-vestibular pathologies that can mimic CGD”
I had one patient with cervical artery dysfunction that presented with a dizziness. The dizziness was produced with neck movements, but not with other testing. It wasn’t until he started to demonstrate a nystagmus with the seated rotation extension test, along with neck pain, that I sent him back to his referring physician. An ultrasound confirmed arterial dissection.
It’s common in my practice to see proprioceptive issues, as tested by the JPET, in patients after a car accident. We use the laser frequently with these patients.
“…as CAD related dizziness presents with only one symptom in less than 1% of the cases. Other symptoms of CAD include severe headache, diplopia, nystagmus, numbness around the lips or mouth, dysphagia, dysarthria, and upper motor neuron signs”
The patients that present with a suspicion of cervical artery dysfunction or dissection should be referred back to the physician immediately, as this is a risk factor for major complications like stroke.
“Common symptoms of WAD are cervical neck pain and hypersensitivity, decreased cervical ROM, dizziness, tinnitus, and headache”
I see the hypersensitivity frequently in the clinic, along with reduced movement in the neck and a fear avoidance mentality. We don’t expect to see hypersensitivity in those with cervical based dizziness.
“Positive results on cervical instability testing or CAD testing indicate a need for immediate medical attention and imaging”
Again, this was stated above, but I will leave the quote as it is very important to get these patients medical attention immediately.
“A neurological screen should include an assessment of radicular symptoms, myotomes, dermatomes, deep tendon reflexes, upper motor neuron signs and cranial nerve function”
This is a basic evaluation.
Has your PT ever checked your lower reflexes or
“…the vestibular examination should be next”
This type of evaluation is looking at the health of the vestibular nerve and possibly the cochlear nerve through special tests.
The semicircular canals are also tested through positional testing, described later in the post.
Some of the testing performed in the clinic are as follows:
Head Impulse Test or Head Thrust
Head shaking test
The DVAT is described below.
“A thorough evaluation of the cervical spine is best performed in step 4 because first ruling out vestibular dysfunction increases the probability that the cervical spine is the cause of the dizziness”
This goes back to the classification of exclusion. If we’ve cleared the brain of signs of stroke, cleared the canals for signs of BPPV, cleared the nerve of signs of hypofunction and looked at other possibilities such as fistula, then we are left with the neck.
Treating the neck can be helpful for many, but it shouldn’t be the first line of treatment for a patient walking off of the street with complaints of dizziness.
The JPET is one way to test the cervical spine for deficits in spatial awareness.
The Head neck differentiation test is another way of assessing the neck region for dizziness.
“…oculomotor evaluation should include evaluation of nystagmus, skew, smooth pursuit, saccades, Dix-Halpike test, static and dynamic visual acuity, and the vestibule-ocular reflex (VOR) including VOR cancellation and the head thrust test”
Another video showing a nystagmus
The Test of skew is a part of the HINTs exam, which could indicate an active stroke.
Smooth pursuit is another test to measure brain involvement in dizziness.
Saccadic testing is easy to perform in the clinic.
The Dix-Hallpike maneuver is classic for testing of the posterior semi-circular canal, which is typically implicated in BPPV.
The DVAT is used to classify BVH and UVH. (I am choosing to use a student page for this one to help support student programs).
“A horizontal, direction, fixed nystagmus, is consistent with unilateral peripheral vestibular hypofunction.”
These are hard to imagine without context. This video is perfect to demonstrate a quick horizontal beat towards the stronger side.
The eyes will slowly drift in one direction and rapidly correct towards the other direction. This is an indication that one vestibular nerve is “stronger” than the opposite nerve.
This can be treated successfully through rehab.
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Dr. Vince Gutierrez, PT 