This article review will also be accompanied by a case study! I had a patient present with cervicogenic dizziness. Having literally ZERO experience with it– just brief 5 minute overviews in vestibular courses– I sought out some assistance from the community at the Neurocollaborative for the differential and treatment ideas. One of the fine therapists there, Jennifer, sent me this article. It was very helpful, so I thought I’d share it and my case.
Polly Patient was in inpatient rehab, because she had been in a car accident that caused several injuries that don’t particularly matter to this part of her case. Her therapist asked me to take a look at her suspecting BBPV, because she was having terrible dizzy spells with sit to supine. Because she had a history of trauma, I started by checking neck ligaments and the vertebral artery. In doing so, I found her neck to be stiff and tender, which Polly admitted had been increasingly painful and that neck extension with vertebral artery testing caused extreme dizziness. I thought this a little odd, but I have had patients with BPPV react to vertebral artery testing like that before– immediate dizziness. So I checked the suspected posterior canals for BPPV with Dix-Hallpike– nothing. Just to be sure, I checked anterior (head hang test) and horizontal (roll test) canals too. Nothing. (You can find those tests simply enough in vestibular books or online.) I had only scheduled 30 minutes for this, since it sounded like an open and shut case of BPPV, but seeing as how it wasn’t and I didn’t know what to do next, I did a little education to kill the last 5 minutes. Then I slipped in that we had run out of time and, no, I didn’t have an answer yet (although I had ruled out 8 things). I told her I suspected her neck might be the root cause and I’d like to check it out tomorrow.
In the article I learned that folks with cervicogenic dizziness can present with 4 different types of problems: disturbed head-neck awareness, neck movement control, postural stability (dizziness and/or unsteadiness), and oculomotor disturbances. Head-neck awareness problems present as “a poor awareness of their head-neck posture, and some indeed complain about ‘a wobbling head’.” This can be clinically captured by testing joint position error. (Click the link to learn more about that test.) I think the special test that Anne, Meg and Valerie in the NeuroCollaborative described for me also falls into this category– the rolling chair test. You compare symptoms to when patient is seated rotating head back and forth to when gaze is stationary and the patient’s trunk is being rotated via the tester rotating a rolling chair. Symptoms being present more with trunk rotations says cervicogenic. This one wasn’t in the article, but since several people recommended it, I thought it worth checking out. Neck movement control issues surface as complaints of a stiff neck, movements that feel “jerky”, “intense tiredness in the back of the neck” or a heavy head. The Fly is a computer program built to assess this (and probably costs a lot of money that I don’t have).
Or you can re-use your laser from the joint position error test and have the patient attempt to trace a pattern with the laser on their head. Postural stability problems have “… complaints of unsteadiness, insecurity, lightheadedness…. feeling a spinning, but this is more like a feeling of ‘spinning in the head’ rather than spinning of the patient or the surroundings, as in typical vertigo of vestibular origin’… tipsy… nausea.” These symptoms can be more noticeable in the morning when the neck is stiff or later in the day when the patient gets tired. Quick head movements also make it worse. To document these problems, you’d do a CTSIB (The article doesn’t call it that, but that’s what it is basically.), “…tandem stance and single leg stance on firm surface with eyes open and closed for up to 30 seconds…”, dynamic gait index (DGI), timed 10-meter walk test with head turns and the step test. (See the article.) Finally, oculomotor disturbances present as complaints of “blurred vision, reduced visual field, temporary blinding, photophobia and disordered fusion… reading problems… [and,] diplopia.” These are assessed with smooth pursuit, gaze stability and saccades. (See the article.)
Polly had several of these issues. She was positive on the joint position error test and rolling chair test. She complained of associated lightheadedness, nausea, spinning sensations and heavy head. The recommended postural stability tests were impossible to perform due to her other injuries, but I will say that her trunk control with sit to supine isn’t the best. All her oculomotor tests were negative and she didn’t have any subjective complaints from that category either. We also found that Polly did have some orthostatic hypotension as well, but she was asymptomatic with it.
There we have the assessment of cervicogenic dizziness, which overall is more a diagnosis of exclusion, meaning that her signs and symptoms don’t fit into any other dizziness category well. Her history of the car crash is also significant in that it suggested I look at her neck.
We’ll look at treatment strategies next time on: adventures in cervicogenic dizziness!