Vertigo is a sense of movement or rotation of the patient’s own or an external object.

When most people think vertigo, the most common diagnosis is benign paroxysmal positional vertigo (BPPV). This is long for BPPV and the same condition as when people think of crystals being out of place.

Most patients with BPPV report vertigo-like episodes when lying down, extending their head or neck, sitting up from a supine position, and bending over.

Another type of vertigo is nautical vertigo.

Nautical vertigo is defined as a sensory illusion reminding of movements experienced on board a ship in waves. It is not nearly as common and quite frankly, very limited information is out on this type of vertigo.

With that said, many patients may experience nautical vertigo instead of the typical symptoms of BPPV even though BPPV is much more prevalent.

In fact, an observational study in 2013 found nautical vertigo and dizziness are more common than rotatory vertigo in patients with chronic BPPV.

This could be due to individuals who suffer from vertigo can also have neck pain, headache, widespread pain, fatigue, visual disturbances, cognitive dysfunctions, nausea, and tinnitus. The combination of several symptoms, especially if chronic, can present differently.

The treatment for this type of vertigo does not always respond favorably to canalith repositioning procedures. Nautical vertigo will need more than cervical therapy too.

Individuals will most likely need more vestibular rehabilitation, sensorimotor training and cervical spine treatment as a more comprehensive approach. This is part of our Physio Blend for Cervicogenic Dizziness Treatment. Therefore, it can help more than those with just Cervicogenic Dizziness but those too with nautical vertigo.

CERVICOGENIC DIZZINESS COURSES AND CERVICAL VERTIGO COURSES

You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course. Pertinent to this blog post, the entire weekend includes the most up-to-date evidence review from multiple disciplines to diagnose through the “Optimal Sequence Algorithm” and treat through the “Physio Blend”.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for prices and discounts.


Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT


Danielle N. Vaughan, PT, DPT, Vestibular Specialist

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Can Craniosacral Osteopathy help Dizziness?

As consistent authors, teachers and clinicians that diagnose and manage dizziness disorders, especially from the cervical spine, we always research the newest information out there to help persons with these conditions.

I found a recent journal article out of Turkey by Atay et al examining the effect of craniosacral osteopathy on dizziness and balance in individuals who have peripheral vestibular pathology.

The participants who were diagnosed with chronic vertigo were divided into two groups:

1. Cranial osteopathy treatment group

• Impairments of cranial, cervical, thoracocervical, and facial dysfunctions were determined by and treated with muscle energy (postisometric relaxation), fascial stretching against tension, and craniosacral treatment methods.
• Prescribed dosage: Total of 6 sessions (once/week for 60 minutes)

2. Dimenhydrinate

• This medicine is an antihistamine over the counter drug intended to treat motion sickness, dizziness, vertigo and nausea.
• Prescribed dosage taken twice/day over 6 weeks
• The visual analog scale, BERG balance test and Activities-Specific Balance Confidence scale were used to define success of the treatment(s) and to analyze within-group changes.

Here are the author's conclusion of comparing the two groups:

• Craniosacral osteopathy resulted in greater improvements in terms of dizziness and balance compared to medical treatment in individuals with chronic peripheral vestibular pathology.
• Craniosacral osteopathy is an effective treatment choice in individuals who have chronic peripheral vestibular pathology.
• In individuals who have resistant and chronic vestibular pathology, craniosacral osteopathy should be evaluated among the treatment choices.

Our Impression of the study

We would say generally speaking, this study is good news! It adds to the plethora of work that shows somatic treatment of the cervical spine and facial structures can assist in improving symptoms of dizziness and vertigo.

Manual Therapy to the Neck for Cervicogenic Dizziness Treatment

This is the basis behind the larger diagnosis of Cervicogenic Dizziness, even though this term was not specifically used in the study. This study would go nicely inside our e-book, "Why the Vestibular Therapist should learn Cervical Manual Therapy" - which is a nice and brief overview of the connections between the somatosensory, visual and vestibular systems.

Even though Osteopathic medicine has been around since 1874, there hasn't been a great deal of actual research studies demonstrating its effects for dizziness and vertigo. Majority of our data that we teach comes from the chiropractic and physical therapy professions, but this doesn't mean that its absence in the literature means its not effective.

Overall, this isn't a strong study by any means. Both groups combined to n=24 and comparison of a "mechanical" treatment against a "chemical" treatment (Dimenhydrinate) isn't mighty to determine if craniosacral osteopathy is superior to vestibular therapy or any other type of manual therapy.

However, if you're a physician who is reading this, it is nice to consider your go-to medications aren't working well, then a manual-based or even vestibular-based practitioner could give your patients superior relief and quality of life.

If you're a vestibular therapist reading this, I would again consider learning techniques to the cervical spine and/or skull & face in an organized manner to provide more strategies in improving pain and function. We provide this data from over 300 references in the literature and our own clinical experience through our Physio Blend to ultimately give you the best of the best to treat individuals with dizziness and/vertigo from a manual standpoint.

You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the author and his wife, a Vestibular Specialist, teach a 2-day course. Pertinent to this blog post, the second day provides the most up-to-date evidence review from multiple disciplines to treat through the “Physio Blend," a comprehensive approach to treating neck pain and dizziness / vertigo symptoms.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for prices and discounts.

Sign up for more emails on this topic by clicking here

reposted from In Touch PT

Authors


Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT


Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts


Danielle N. Vaughan, PT, DPT, Vestibular Specialist


Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Learn more online - new online discussion group included!

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. 

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Out of Iran and part of PhD work, Dr. Ronak Zagar, and colleagues in a 2020 study examined this just question.

The study examined muscle thickness of both the anterior and posterior cervical muscles using ultrasound between persons diagnosed with cervical vertigo and compared the results to healthy controls.  Figure 1 from the study is shown below:

[caption id="attachment_5298" align="aligncenter" width="750"] Ronak Zargar Talebi et al. Evaluation of cervical spine muscles thickness in patients with cervical vertigo and healthy controls through ultrasonographyJ Phys Ther Sci. 2020 Jul; 32(7): 439–443.[/caption]

The cervical flexors (anterior muscles) studied were:

1. Sternocleidomastoid

2. Longus Colli

3. Longus Capitis

The cervical extensors (posterior muscles) studied were:

1. Rectus Capitis Posterior Major bil

2. Obliquees Capitis Inferior bil

The main findings of the study were:

The thickness of extensor muscles was not significantly different between the patients with cervical vertigo and healthy participants.

The Longus Colli thickness was higher in the patients with cervical vertigo than healthy subjects.

How do the authors interpret this research?

The authors hypothesized that the higher thickness of Longus Colli may a compensatory mechanism in the patients with cervical vertigo.  

They go on to write,

Due to the small number of the literature in the field of RUSI, clinical interpretation of the findings is difficult and more studies are required to confirm results of our study, but so far, it can be suggested that the clinicians take into account the findings of this study in the evaluation of patients with cervical vertigo and incorporated the cervical stabilization exercises in the treatment planning for the cervical vertigo.

How do we interpret this research as clinicians?

It is inherently known in the rehabilitation profession that a mis-match exists between the deep and superficial deep cervical flexors and extensors in individuals with vertigo, dizziness, neck pain, whiplash, mTBI and concussion.  The mis-match can vary depending on the plethora of studies performed over the last 20 years, but generally speaking, there is a motor control disturbance placing too much of a demand on the superficial vs deep musculature.

The current study is quite interesting that prior to reading it, I would have hypothesized that the Sternocleidomastoid (SCM) would have higher thickness values.  Instead, the findings are the opposite, with the Longus Colli taking first place.

Overall, I utilize this one study as another puzzle piece for a multi-sensory condition.  This does not change my practice patterns.  I will not stop inhibiting the SCM and aim to activate the Longus Colli more effectively as this works and works well.

This research makes medicine and science interesting and progressive.  I am glad we now have the technology to perform these types of studies in rehabilitation and I look forward to future research by this group or other groups to continue to help others.

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You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the author and his wife, a Vestibular Specialist, teach a 2-day course.  Pertinent to this blog post, the first day provides the most up-to-date evidence review from multiple disciplines to diagnose through the “Optimal Sequence Algorithm” to assist in ruling out disorders and ruling in cervical spine, including determining if single or double entity exists.  

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for prices and discounts.

Sign up for more emails on this topic by clicking here

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Learn more online - new online discussion group included!

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. 

• NEW - Online Discussion Group
• Live cases
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• Check out MMT Insiders

Keeping it Eclectic...

Of course anyone reading this blog over the last several years realizes the intent is to rule in and rule out the cervical spine as a driver for the symptoms of dizziness, lightheadiness, drunkenness and unsteadiness.

Therefore, the question, “Can the teeth cause dizziness” is an interesting inquiry and not a common source of dizziness.  However, for anyone treating upper quarter symptoms, it is pertinent to know a few of these outliers.

I would like to initially relay material from a 2019 case report entitled, “Recovering of Dizziness of a Patient with Sinusitis after Root Canal Therapy for Upper Second Molar”.

Here are some of the highlights:

• 26-year-old male had suffered from dizziness in walking and standing.  He had a headache while eating and tilting his head forward.
• The patient consulted internal, cardiac, and neurological and ENT specialists to treat the dizziness but no success.
• Videonystagmography, Cervical MRI normal and brain MRI showed sinusitis.
• The patient sought out dental services.  Without getting into details of the diagnostic and treatment approach, he basically underwent root canal therapy.
• Two months after the intervention, the patient reported a complete recovery of dizziness and sinusitis; pain was reported as 0/10.

The conclusion from Amro et al:

• Sinusitis is a common etiology of dizziness, but sinusitis of odontogenic cause associated with dizziness had not been discussed in literature according to the knowledge of the authors, which is the main finding of this article.
  • This is the main concept I want to relay to our readers too…
• In this case, dizziness was recovered, after the sinusitis had improved, with no major intervention other than root canal therapy
• Recommendations of this study include the evaluation of any dizzy patient must include dental history and examination, to exclude any causes of dental origin.

Anyone who knows us, knows we like case reports and recommend students read these as well to help understand a clinical reasoning process.  I just gave you a short synoposis above, but recommend you read the full text from the journal, Case Reports in Dentistry.  Lucky us, it is open access article and can be found here!

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You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the author and his wife, a Vestibular Specialist, teach a 2-day course.  Pertinent to this blog post, the first day provides the most up-to-date evidence review from multiple disciplines to diagnose through the “Optimal Sequence Algorithm” to assist in ruling out disorders and ruling in cervical spine, including determining if single or double entity exists.  

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for prices and discounts.

Sign up for more emails on this topic by clicking here

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Learn more online - new online discussion group included!

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. 

• NEW - Online Discussion Group
• Live cases
• webinars
• lecture
• Live Q&A
• over 600 videos - hundreds of techniques and more! 
• Check out MMT Insiders

Keeping it Eclectic...

Science begets more science.

That is how we continue to advance and propel ourselves forward in neuromusculoskeletal rehabilitation.

For over the past decade, we have treated dizzy/vertigo and neck pain disorders.  We have allowed guidelines and clinical expertise guide us to treat these conditions when presented to us independently.  More memorable to us is what we have created together (orthopedic and vestibular therapist) when these symptoms are combined or overlap.  We call this our Physio Blend.

Most clinicians can agree that these symptoms are combined more often than simply independent entities but difficult to “prove” via research.  During our teaching, we discuss the research on the double entity — i.e. multiple systems contributing to symptoms — but today, we present to you 5 charts showing why neck pain and dizziness are correlated in research.

1. Concussion Research

 

Concussion Research (Source: Pubmed) from 1990-2019)

Concussion, in general, has by far had the greatest attention in the medical industry in the past few years.  As you can even see from the graph above, a huge spike starting occurring around 2012 and has skyrocketed over 300%.  For those in the clinic treating Post-Concussion Syndrome, you are well aware of the multiple systems (and professionals) needed to treat the individual entirely.  Read more about this topic from a previous post here and here.

2. “Neck Pain and Dizziness” Research

“Neck Pain and Dizziness” Search from 1990-2019

When I searched for the combined phrase, “Neck Pain and Dizziness”, I did not expect to find such a spike in research over the past several years.  Obviously this does make sense clinically as this is what we see (and teach), but good to see the research catching up.  For you all in the clinic, I know you see an improvement in neck pain patients when treating the neck and could also see a spike in improvements with neck pain when treating the vestibular system. Read more about this topic from a previous post here and here.

3. “Neck Pain and Vertigo” Research

 

“Neck Pain and Vertigo” Search from 1990-2019

Vertigo as a symptom is not nearly as correlated clinically as dizziness as a symptom when speaking of Cervicogenic Dizziness, but can’t deny the overlap of terms in the clinic and research.  Interesting there is a big spike from 2017 to 2019 with articles (almost double) with this phrase.  We have written about the controversy between professions over this topic and you can read more about it here.

4. Cervical Vertigo Research

Cervical Vertigo Search from 1990-2019

Cervical Vertigo should be becoming more antiquated of a term and you can certainly see a drop in this phrase in the research starting in 2014.  One of our most popular articles discusses this topic and you can read more about it here.

5. Cervicogenic Dizziness Research

Cervicogenic Dizziness Search from 1990-2019

You may wonder why we actually left the phrase, “Cervicogenic Dizziness” for last in this article considering this is the main expression or our combined knowledge.  You can see from the chart above that this is the least common terminology and nothing was found of it prior to the year 2000 when Diane Wrisley’s most famous article came out.  I think you can take out of this chart is that if you want to research an article, you need to look at multiple search items and not limit yourself to one phrase.  This is how we created the research behind our Physio Blend — by examining the works of the osteopaths, acupuncturists, chiropractors, physios and surgeons.  We really need to favor conservative care for this condition and you can read more about this topic here.

 So there you go!  You can see a trend towards having knowledge of multiple systems to fully treat someone with dizziness, vertigo and neck pain.

You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the author and his wife, a Vestibular Specialist, teach a 2-day course.  Pertinent to this blog post, the first day provides the most up-to-date evidence review from multiple disciplines to diagnose through the “Optimal Sequence Algorithm” to assist in ruling out disorders and ruling in cervical spine, including determining if single or double entity exists.  

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for prices and discounts.

Sign up for more emails on this topic by clicking here

reposted with permission from In Touch PT Blog

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Learn more online - new online discussion group included!

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. 

• NEW - Online Discussion Group
• Live cases
• webinars
• lecture
• Live Q&A
• over 600 videos - hundreds of techniques and more! 
• Check out MMT Insiders

Keeping it Eclectic...

What is Cervicogenic Dizziness?

Physiologically, cervical dizziness is explained by the presence of connecting fibers between the somatosensory system of the cervical spine and the vestibular nuclei.  Through these fibers, afferent somatosensory information from the cervical spine can alter the spontaneous firing rates and synchrony of firing among neurons in the vestibular nuclei.

When the somatosensory influence turns out to be a major influencing factor compared to the otolith, semicircular and optical stimuli, the symptoms can be called cervicogenic dizziness.  When the compensation fails from these systems, a vestibular syndrome can occur. The symptoms are usually described as dizziness, lightheadedness, unsteadiness or drunkeness.  True vertigo is rare and typically not a symptom of cervical origin. 

Overall, we can consider these patients to have postural instability and altered head on neck awareness.  The practical consequences to the patient may be dizziness in the short term and imbalance and falls in the long term.  

How do you diagnose Cervicogenic Dizziness?

Symptom provocation is initiated following active or passive neck torsion, typically in a cervical extension or rotation manner. Cervicogenic Dizziness has a different nature and behavior compared to benign paroxysmal positioning vertigo (BPPV) and vertebral-basilar insufficiency (VBI) and it is generally not associated with neurological signs and symptoms.

Several reasons have been described for altered sensorimotor input from the cervical spine.  These usually include acute or chronic neck pain, stiffness and trauma.  Trauma is typically following a fall, whiplash-associated disorder and/or concussion.  Other reasons can be due to accompanying decreased mobility and cervical muscular tone secondary to a peripheral dysfunction.  Due to these factors, cervical dizziness can be described as a single entity or double entity condition.

How do you treat Cervicogenic Dizziness?

Non-invasive cervicothoracic, orofascial and/or shoulder girdle treatment is the best recommendation for initial management of cervicogenic dizziness.  Statistically relevant improvements from manual therapy and exercise in the immediate, short-term and long-term has been found in clinical research to decrease frequency of dizziness, intensity of dizziness, intensity of pain and positive changes on functional outcome measures.  Systematic reviews over the past 15 years have consistently concluded positive changes from joint mobilization and/or manipulation.

Improving neck mobility, decrease viscosity and stiffness, and dampening pain is the first course of action of treatment.  Secondarily, improving eye–head kinematics and gaze accuracy by voluntarily increasing head movement amplitudes and head contributions to gaze saccades may lessen symptoms, improve stability, and reduce falls (Johnston et al 2017). 

The improvement of symptoms can be attributed to restoration of cervical mobility and motor control with head on neck orientation.  Since two-thirds of extra cranial vestibular signals are from the cervical spine, achieving balance of proprioceptive and nociceptive input to the central nervous system from the joints and muscle spindles is key management.  This appears to achieve balance in afferent input from multiple systems to the vestibular nuclei that aid in the complex nature of postural control.  Therefore, initially, the disappearance of some of these symptoms is related to changes in neural activity in the vestibular nucleus from changes in the afferent information from the cervical spine.

Do patients with Cervicogenic Dizziness get better?

Patients generally have a very good prognosis, especially if simply a single entity sub-diagnosis.  A double entity sub-diagnosis will require further assessment and treatment procedures to see response in symptoms to then provide the prognosis.  We usually can provide a more detailed analysis after a few sessions to see how the patient responds to multiple therapeutic approaches.

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You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the author and his wife, a Vestibular Specialist, teach a 2-day course.  Pertinent to this blog post, the first day provides the most up-to-date evidence review from multiple disciplines to diagnose through the “Optimal Sequence Algorithm” to assist in ruling out disorders and ruling in cervical spine, including determining if single or double entity exists.  

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for prices and discounts.

Sign up for more emails on this topic by clicking here

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopractic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Learn more online - new online discussion group included!

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. 

• NEW - Online Discussion Group
• Live cases
• webinars
• lecture
• Live Q&A
• over 600 videos - hundreds of techniques and more! 
• Check out MMT Insiders

Keeping it Eclectic...