CERVICAL VERTIGO

INTRODUCTION
Cervical vertigo is a poorly defined condition, perhaps only a theoretical possibility (Brandt, 1996). The main reason for this is that there are no clear-cut or reliable clinical tests by which the presence of cervical vertigo may be determined. It is generally accepted that proprioceptors in the neck play an important role in the regulation of balance and it would seem logical that interference with the function of these proprioceptors could lead to dysequilibrium. Experimental evidence in laboratory animals and in man supports the hypothesis that damage to the neck will result in dizziness. There is a growing literature base, which provides clinical evidence for the beneficial treatment of vertigo/dizziness where there is associated pain and cervical dysfunction and where other causes of vertigo/dizziness have been excluded.

CLASSIFICATION OF CERVICAL VERTIGO

The term cervical vertigo is often disputed as it is generally thought that patients are more likely to complain of dizziness rather than true vertigo. Cervical vertigo/dizziness may be considered under three headings Cervical dizziness/dysequilibrium, Posterior cervical sympathetic syndrome, Cervical pathology causing vertebro-basilar insufficiency (VBI).

Cervical dizziness/dysequilibrium Much of the following discussion relates to this particular putative aetiology. Posterior cervical sympathetic syndrome Otherwise known as the "posterior sympathetic syndrome of Barre-Lieou" (Brown, 1992). Barre and Lieou proposed that cervical lesions might irritate the sympathetic vertebral plexus and result in a decreased blood flow to the labyrinth due to constriction of the internal auditory artery. Little objective data exists to support an association between episodic vertigo and cervical sympathetic dysfunction (Baloh & Honrubia, 1990). Hinoki (1985) suggests that irritation of the posterior cervical sympathetic system can induce over-excitation of the cervical proprioceptors. Cervical pathology causing vertebro-basilar insufficiency Vertebro-basilar insufficiency may be defined as episodes of relative ischaemia in the area of distribution of the vertebrobasilar system that result from a temporary alteration in flow in that system and its branches giving rise to symptoms, one of which may be vertigo. The vertebral arteries pass through, and are protected by, the cervical vertebrae, and trauma, pathology including upper cervical instability or congenital abnormalities may be responsible for this condition. VBI diagnosis and testing is, in itself, a controversial topic. It is not the

intention of the author to discuss this issue in this document and the reader is referred to the reference list for articles on pre-manipulative testing (Thiel et al, 1994; Haynes, 1996; Terenzi & DeFabio, 1996; Rivett et al, 1998; Rivett et al, 2000; Li et al, 1999; Barker et al, 2000; Licht et al, 2000; Johnson et al, 2000; Guidelines of the Australian Physiotherapy Association, 2000). The presence of VBI is likely to affect the type of physiotherapy treatment chosen and must be precluded before any cervical manipulation is attempted.

THE ROLE OF CERVICAL PROPRIOCEPTORS IN BALANCE

Sensory information from the vestibular apparatus is combined with visual information and somatosensory input, including the neck, to assist in the control of equilibrium and spatial orientation. Proprioceptors in the zygapophyseal joints of the cervical spine and supporting musculature send impulses to the vestibular nuclei and to the brain stem. These neck afferents not only assist in co-ordination of the eyes, head and body in space, but also affect spatial orientation and control of posture. It is thought that neck afferents are involved in three posture-related reflexes, the cervico-collic, the tonic neck reflex and the cervical-ocular reflex (Bolton, 1998). The cervico-collic reflex This functions to stabilise the head in space (Bolton, 1998) and is thought to involve the activation of neck muscles when they are stretched, e.g. when the head is turned in relation to the body or vice versa. This is believed to be integrated with other reflexes involved in balance, e.g. vestibulo-collic. The tonic neck reflex This reflex is thought to cause asymmetrical activation of limb muscles in response to neck rotation. According to Brandt (1996) it can only be elicited in new-borns. However, Fukuda (1983, quoted in Shepard and Telian, 1996) suggests that the reflex may not disappear but simply be reduced in activity in adults. Gurfinkel (1992) states that head rotations induce changes in the distribution of tonic activity of limb muscles in man but that there is no reason to consider this is a direct response to activation of neck muscle receptors. The cervico-ocular reflex This produces a slow phase eye movement in the opposite direction to head movement during low frequency head movements to assist in maintenance of stable gaze (Herdman, 1994). Hikosaka and Maeda (1973) found connections between neck afferents from the dorsal roots and cervical joints at level C2/C3 and the vestibular nuclei where they interact with the vestibulo-ocular reflex activity to the abducens motor neurones. The gain is low ,< 0.07 Hz (Sawyer et al, 1994) or approximately 0.3 (Brandt, 1996) and is thought to make a negligible contribution to the stability of gaze in normal subjects (Sawyer et al, 1994).

EXPERIMENTAL EVIDENCE
It is argued that injury to the neck may result in a disturbance in the reflexes described above and lead to episodes of dizziness, vertiginous sensations and cervical nystagmus. Experimental evidence published by De Jong et al (1977), Hinoki (1985), Hlse (1983) and others show that altered input from the cervical spine can produce symptoms of imbalance,

vertigo and/or dizziness.

CAUSES (CLINICAL)
Altered proprioception may be due to injury or pathology such as cervical spondylosis, disc prolapse, instability (e.g. rheumatoid arthritis, post traumatic), or trauma (e.g. whiplash). Pain may inhibit the deep cervical muscles causing altered proprioceptive input.

DIAGNOSIS OF CERVICAL VERTIGO

It is a diagnosis of elimination, i.e. all other causes of dizziness, vertigo and imbalance should be ruled out wherever possible (Wrisley et al, 2000). There should be a close temporal relationship between neck pain and symptoms of dizziness. There should also be a history of neck injury or pathology. The type and severity to induce cervical dizziness is not known.

TESTING
A. IN THE LABORATORY Posturography Karlberg et al (1996) presented their findings from a prospective controlled study in patients with dizziness or vertigo of suspected cervical origin in whom extra-cervical causes had been excluded and where posturography performance was impaired. Smooth Pursuit Torsion Test Tjell (1998) found that smooth pursuit eye movements (in neutral and at 45O left and right) was useful for diagnosing cervical dizziness in patients with whiplash associated disorders. E.N.G Shepard & Telian (1996) suggested that cervical induced nystagmus may be a possibility when there is consistent positional nystagmus that is direction fixed and specific for neck torsion, regardless of the orientation of the head relative to gravity. Nystagmus is eliminated whenever the head is straight relative to the torso. (More detail is provided in Chapter 4 of Practical Management of the Balance Disorder Patient). B. BEDSIDE TESTING Head on Body Rotation. Fitz-Ritson (1991) presented the results of a trial on cervical-traumatised patients. 47% of patients examined had symptoms of vertigo alone when tested on a rotating stool (head fixed with body rotating). Head Repositioning (Testing for altered kinaesthetic performance)

Heikkil et al (2000), using the work of Revel et al (1991), assessed the ability of patients with dizziness of suspected cervical origin to perceive the position of the head relative to the trunk and found it to be less precise than a control group C. PATIENT PRESENTATION Clinical and experimental signs and symptoms reported in the literature are somewhat varied and, on occasions, contradictory. Most authors are in agreement that neck pain is a prerequisite although the mechanistic relationship between neck pain and vertigo has not been fully identified. Listed below are some possible characteristics in patients complaining of cervical vertigo (cervical dizziness/dysequilibrium) Subjective complaints of Imbalance or dysequilibrium (Brown, 1992), Vertigo (rotation of self or environment) (Fitz-Ritson, 1991), Dizziness (Heikkil et al, 2000; Hinoki, 1985), Dysequilibrium with vertigo (Karlberg et al, 1996), Sensation of falling/tilting or being pulled to one side (de Jong et al, 1977), Headache (Karlberg et al, 1996; Hinoki, 1985), Neck pain (Wrisley et al, 2000), Motion sensitivity (Wrisley et al, 2000). Most papers suggest the dizziness is non rotational. Objective findings of Altered cervical spine movement/dysfunction (Galm et al 1998), Altered smooth pursuit (neck torsion test; Tjell, 1998), Movement abnormalities of the cervical spine (Heikkil et al, 2000), Altered kinaesthetic performance (Heikkil et al, 2000), Vertigo induced by body-on-head rotation (Fitz-Ritson, 1991), Ipsilateral arm and leg hypotonia (de Jong et al, 1977), Posture instability on turning (Brown, 1992), Normal caloric (Brown, 1992), Abnormal posturography (Karlberg et al, 1996).

TREATMENT
Evidence for the successful treatment of cervical dizziness can be found in Heikkil et al (2000), Karlberg et al (1996) and Wrisley et al (2000). Treatment is directed at the painful soft tissues and painful and/or stiff joints. There are a variety of treatment options including massage, acupuncture, stretching, etc. Stiff joints are treated with mobilisation and/or manipulation. Appropriate activation of deep cervical supporting muscle fibres is encouraged and specific exercises to improve proprioception, balance and gait should be included. Treatment of choice is decided after a thorough assessment of active and passive joint range

of movements, muscle recruitment, length and tenderness and, where appropriate, neural and neurological systems will be assessed. Kinaesthetic performance, balance tests and evaluation of gait should also be included, motion sensitivity testing should be performed when subjective complaints are found. Vertebral artery and upper cervical stability testing may need to be included. Treatment is continuously evaluated at each session and adjusted in relation to patient's presentation. Goals of treatment should be set at the initial evaluation and should include pain relief, reduction of dizziness, improved range of movements, improved balance and kinaesthetic performance scores and functional targets.

SELECTED REFERENCES AND FURTHER READING

Australian Physiotherapy Association. Clinical guidelines for pre-manipulative procedures for the cervical spine. April 2000. Baloh, R & Honrubia, V, (1990). Other neurologic disorders. In Baloh, R & Honrubia, V, editors. Clinical Neurophysiology of the Vestibular System. Philadelphia: FA Davis & Co: 274-280. Barker, S, Kesson, M, Ashmore, J, Turner, G, Conway, J & Stevens, D, (2000). Guidance for pre-manipulative testing of the cervical spine. Man. Therapy., 5 (1): 37-40. Bolton, P, (1998). The somatosensory system of the neck and its effects on the central nervous system. J. Manip. & Physiol. Therapy., 21 (8): 553-563. Brandt, T, (1996). Cervical vertigo - reality or fiction? Audiol. Neurootol. 1 (4):187-96. Brandt, T & Bronstein AM, (2001). Cervical vertigo. J. Neurosurg Psychiatry., 71: 8-12. Brown, J, (1992). Cervical contribution to balance: cervical vertigo. In Berthoz, A, editor. Head, Neck and Sensory Motor system. New York/Oxford: Oxford University Press: 644647. De Jong, P, de Jong, V, Cohen, B & Jonkees, L, (1977). Ataxia and nystagmus induced by injection of local anesthetics in the neck. Ann. Neurol. 1: 240-246. Fitz-Ritson, D, (1991). Assessment of cervicogenic vertigo. J. Manip. Physiol. Therapy., 14 (3): 193-198. Galm, R, Rittmeister, M & Schmitt, E, (1998). Vertigo in patients with cervical spine dysfunction. Eur. Spine J., 7 (1): 55-8. Gurfinkel, V, Lebedev, M & Levick, Y, (1992). What about the so-called neck reflexes in humans? In Berthoz, A, editor. Head, Neck and Sensory Motor System. New York/Oxford: Oxford University Press: 644-647. Haynes, M, (1996). Doppler studies comparing the effects of cervical rotation and lateral flexion on vertebral artery blood flow. J. Manip & Physiol. Therapy., 19 (6): 378-384.

Heikkil, H, Johansson, M & Wenngren, B-I, (2000). Effects of acupuncture, cervical manipulation and NSAID therapy on dizziness and impaired head positioning of suspected cervical origin: a pilot study. Manual Therapy, 5 (3): 151-157. Herdman, S, (1994). Assessment and management of bilateral vestibular loss. In Herdman, S, editor. Vestibular Rehabilitation. Philadelphia: FA Davis & Co: 316-330. Hikosaka O & Maeda M, (1973). Cervical effects on abducens motoneurons and their interaction with vestibulo-ocular reflex. Exp. Brain Res.,18: 512-539. Hinoki, M, (1985). Vertigo due to whiplash injury: a neurotological approach. Acta Otolaryngol. (Stockh.), 419: 9-29. Hlse, M, (1983). Disequilibrium caused by a functional disturbance of the upper cervical spine. Clinical aspects and differential diagnosis. Manual Medicine, 1: 18-23. Karlberg, M, Magnusson, M, Malmstrm, E-M, Melander, A & Moritz, U, (1996). Postural and symptomatic improvement after physiotherapy in patients with dizziness of suspected cervical origin. Arch. Phys. Med. Rehabil., 7: 874-882. Li, Y-K, Zhang, Y-K, Lu, C-M & Zhong, S-Z, (1999). Changes and implications of blood flow velocity of the vertebral artery during rotation and extension of the neck. J. Manip & Physiol. Therapy., 22 (2): 91-95. Revel M, Andre-Deshays C & Minguet M (1991). Cervicocephalic kinaesthetic sensibility in patients with cervical pain. Archives Physical Medicine and Rehabilitation 72: 288-291. Rivett, D, Milburn, P & Chapple, C, (1998). Negative pre-manipulative vertebral artery testing despite complete occlusion: a case of false negative? Man. Therap., 3 (2): 102-107. Rivett, D, Sharples, K & Milburn, P, (2000). Vertebral artery blood flow during premanipulative testing of the cervical spine. In - Proceedings of The International Federation of Orthopaedic Manipulative Therapists, 2000. Pages 387-390. Sawyer, R, Thurston, S, Becker, K, Ackley, C, Seidman, S & Leigh, R, (1994). The cervicoocular reflex of normal human subjects in response to transient and sinusoidal trunk rotations. J. Vestib. Res., 4 (3): 245-249. Shepard, N & Telian, S, Editors. Practical management of the balance disorder patient. San Diego & London: Singular Publishing Group, 1996. Terenzi, T & DeFabio, D, (1996). The role of transcranial Doppler sonography in the identification of patients at risk of cerebral and brainstem ischaemia. J. Manip & Physiol. Therap., 19 (6): 406-414. Thiel, H, Wallace, K, Donat, J & Yong-Hing, K, (1994). Effect of various head and neck positions on vertebral artery blood flow. Clin. Biomech., 9: 105-10.

Tjell, C & Rosenhall U, (1998). Smooth pursuit neck torsion test: A specific test for cervical dizziness. The American Journal of Otology 19: 76-81. Wrisley, D.M. et al (2000). Cervicogenic Dizziness: A review of diagnosis and treatment. Journal of Orthopaedic & Sports Physical Therapy., 30 (12): 755-766.

The author of this document has selected some key papers in this area with the intention of stimulating interest and provoking discussion. This is by no means intended to represent a full literature survey of this complex area. Jane E. Harrison MCSP, SRP The Lister Hospital, Stevenage