Cervicogenic Dizziness | Diagnosis & Treatment

Introduction & Pathophysiology

Cervicogenic dizziness is defined as “a non-specific sensation of altered orientation in space and disequilibrium” and it is related to neck dysfunction. It is more frequently present in females and in people with sitting jobs or in those with sustained neck positions during work. The dizziness complaint is often more a sensation of lightheadedness in combination with disequilibrium.

Pathomechanism

Cervicogenic dizziness is caused by a sensory mismatch of the afferent information of the neck. Important proprioceptive structures like muscle spindles and nerve receptor endings are located in the neck. Therefore, this region is important for postural control and balance. Due to a cervical dysfunction (originating from a mechanical, degenerative or inflammatory disorder), a sensory mismatch of the afferent cervical proprioceptive input with sensory input from the visual and vestibular system occurs. This abnormal afferent input from cervical joint receptors/mechanoreceptors to the vestibular nucleus causes a mismatch with the information from the vestibular and visual systems.

Triggers may be:

• (Quick) neck movements, for example, neck extension when looking up
• Reduced ROM of the neck
• Neck pain
• Certain (sustained) neck positions

Clinical Picture & Examination

Signs and symptoms

In the history taking, it becomes clear that the patient has co-existing neck symptoms. The cervicogenic dizziness develops gradually, is episodic and can last several minutes to hours. Movements of the head and neck reproduce the dizziness symptoms. Typically, the dizziness is non-rotatory, but rather a sensation of disorientation, lightheadedness, or disequilibrium that is accompanied by neck pain, reduced neck ROM and balance.

Examination

Importantly, cervicogenic dizzines is a diagnosis of exclusion. This means that first other central and vestibular causes of dizziness should be excluded.

During inspection, forward head posture, greater shoulder protraction, and a “slouched” posture may be observable. Though these positions are generally not pathological, they may alter the loads in the neck and shoulder girdle due to altered muscle functioning. Palpation may reveal muscle soreness and a feeling of tightness upon palpation of the neck and shoulder girdle muscles.

Active examination

Measurement of active neck range of motion to determine the need for cervical joint mobilization.

Joint position sense should be assessed. A study by De Vestel et al. in 2022 found that patients with cervicogenic dizziness had larger errors with the joint position sense test upon neck extension.

Measures of balance could include static balance for example in tandem stance and dynamic balance during for example the Timed-up and Go-test, tandem gait or functional Gait Assessment. It was found that larger joint position sense error, a high score on the Neck Bournemouth Questionnaire and better Tandem Gait scores were associated with higher odds of having cervicogenic dizziness.

Passive examination

Palpation of the neck can reveal tenderness in the suboccipital region. Palpation of the cervical transverse processes of C1 and C2, spinous processes of C2 and C3 may reveal local or spreading pain or may provoke the sensation of cervicogenic dizziness. Palpation of the levator scapulae, splenius, rectus, semispinalis and upper trapezius muscles can be done to evaluate the muscle tone.

To assess whether mobility of the upper and lower cervical spine and cervicothoracic junction is impaired and thus possibly underlying the cervicogenic dizziness, the following tests can be performed.

• Flexion-rotation test

• Direct upper cervical PIVMs in sitting postion
• Indirect upper cervical PIVMs in supine
• Direct mid cervical PIVMs in sitting postion
• Upper thoracic spine assessment in flexion and extension

Strength and endurance

To assess the strength and endurance, the following tests can be done.

• Cranio-cervical flexion test
• Test of Harris – Deep neck flexor endurance test
• Cervical extensor endurance test

Dizziness specific assessment

Certain specific tests can be done to evaluate cervicogenic dizziness

• Cervical torsion test

• Smooth pursuit neck torsion test
• Head-neck differentiation test
• Postural balance
• Cervical relocation test
• Saccadic eye movement test
• Gaze stability test
• Eye/head coordination test

Treatment

Ideally, treatment should be targeted to the findings from the examination. Manual therapy with direct or indirect upper cervical PIVMs, cervical SNAGs can be used in case the examination reveals range of motion restrictions. A traction-manipulation of the cervical spine and/or the cervicothoracic junction may be performed to promote the positive neurophysiological effects

Strengthening and endurance should be performed to enhance strength of the upper cervical spine. Deep neck flexor and extensor exercises are easy to perform and can be done easily at home or work.

Sensorimotor training should be incorporated when the examination reveals errors in joint position sense, difficulties with eye movement control, and postural balance.

• Proprioception/joint position sense exercises
• Oculomotor exercises
• Postural stability balance training

References

De Vestel C, Vereeck L, Van Rompaey V, Reid SA, De Hertogh W. Clinical characteristics and diagnostic aspects of cervicogenic dizziness in patients with chronic dizziness: A cross-sectional study. Musculoskelet Sci Pract. 2022 Aug;60:102559. doi: 10.1016/j.msksp.2022.102559. Epub 2022 Mar 26. PMID: 35364427. 

Malmström EM, Karlberg M, Melander A, Magnusson M, Moritz U. Cervicogenic dizziness – musculoskeletal findings before and after treatment and long-term outcome. Disabil Rehabil. 2007 Aug 15;29(15):1193-205. doi: 10.1080/09638280600948383. PMID: 17653993. 

​​Devaraja K. Approach to cervicogenic dizziness: a comprehensive review of its aetiopathology and management. Eur Arch Otorhinolaryngol. 2018 Oct;275(10):2421-2433. doi: 10.1007/s00405-018-5088-z. Epub 2018 Aug 9. PMID: 30094486.

Yaseen K, Hendrick P, Ismail A, Felemban M, Alshehri MA. The effectiveness of manual therapy in treating cervicogenic dizziness: a systematic review. J Phys Ther Sci. 2018 Jan;30(1):96-102. doi: 10.1589/jpts.30.96. Epub 2018 Jan 27. PMID: 29410575; PMCID: PMC5788784.

Knapstad MK, Nordahl SHG, Goplen FK. Clinical characteristics in patients with cervicogenic dizziness: A systematic review. Health Sci Rep. 2019 Jul 26;2(9):e134. doi: 10.1002/hsr2.134. PMID: 31624772; PMCID: PMC6784794.

Yacovino DA, Hain TC. Clinical characteristics of cervicogenic-related dizziness and vertigo. Semin Neurol. 2013 Jul;33(3):244-55. doi: 10.1055/s-0033-1354592. Epub 2013 Sep 21. PMID: 24057828.

Reid SA, Callister R, Snodgrass SJ, Katekar MG, Rivett DA. Manual therapy for cervicogenic dizziness: Long-term outcomes of a randomised trial. Man Ther. 2015 Feb;20(1):148-56. doi: 10.1016/j.math.2014.08.003. Epub 2014 Aug 27. PMID: 25220110.

Sung YH. Upper cervical spine dysfunction and dizziness. J Exerc Rehabil. 2020 Oct 27;16(5):385-391. doi: 10.12965/jer.2040612.306. PMID: 33178639; PMCID: PMC7609854.

Carrasco-Uribarren A, Rodriguez-Sanz J, López-de-Celis C, Pérez-Guillen S, Tricás-Moreno JM, Cabanillas-Barea S. Short-term effects of the traction-manipulation protocol in dizziness intensity and disability in cervicogenic dizziness: a randomized controlled trial. Disabil Rehabil. 2022 Jul;44(14):3601-3609. doi: 10.1080/09638288.2021.1872719. Epub 2021 Jan 20. PMID: 33470861.

Carrasco-Uribarren A, Rodríguez-Sanz J, López-de-Celis C, Fanlo-Mazas P, Cabanillas-Barea S. An upper cervical spine treatment protocol for cervicogenic dizziness: a randomized controlled trial. Physiother Theory Pract. 2022 Nov;38(13):2640-2649. doi: 10.1080/09593985.2021.1972500. Epub 2021 Sep 8. PMID: 34496721.

Treleaven J, Joloud V, Nevo Y, Radcliffe C, Ryder M. Normative Responses to Clinical Tests for Cervicogenic Dizziness: Clinical Cervical Torsion Test and Head-Neck Differentiation Test. Phys Ther. 2020 Jan 23;100(1):192-200. doi: 10.1093/ptj/pzz143. PMID: 31584656.

L’Heureux-Lebeau B, Godbout A, Berbiche D, Saliba I. Evaluation of paraclinical tests in the diagnosis of cervicogenic dizziness. Otol Neurotol. 2014 Dec;35(10):1858-65. doi: 10.1097/MAO.0000000000000506. PMID: 25058834.

De Vestel C, Vereeck L, Reid SA, Van Rompaey V, Lemmens J, De Hertogh W. Systematic review and meta-analysis of the therapeutic management of patients with cervicogenic dizziness. J Man Manip Ther. 2022 Oct;30(5):273-283. doi: 10.1080/10669817.2022.2033044. Epub 2022 Apr 6. PMID: 35383538; PMCID: PMC9487935.

Chu ECP, Lo FS, Bhaumik A. Plausible impact of forward head posture on upper cervical spine stability. J Family Med Prim Care. 2020 May 31;9(5):2517-2520. doi: 10.4103/jfmpc.jfmpc_95_20. PMID: 32754534; PMCID: PMC7380784.

Vural M, Karan A, Albayrak Gezer İ, Çalışkan A, Atar S, Yıldız Aydın F, Coşkun Benlidayı İ, Gökşen A, Koldaş Doğan Ş, Karacan G, Erdem R, Eda Kurt E, Kesiktaş FN, Aydın T, Şahin N, Aydın Z, Ordahan B, Türkoğlu G, Reşorlu H, Döner D, Yılmaz F, Bertan H, Dülgeroğlu D, Karaahmet ÖZ, Sonel Tur B, Moustafa E, Borman P, İskender Ö, Ay S, Kurtaran A, Şirzai H, Evcik D, Çapan N, Erhan B, Alptekin HK, Ural Hİ. Prevalence, etiology, and biopsychosocial risk factors of cervicogenic dizziness in patients with neck pain: A multi-center, cross-sectional study. Turk J Phys Med Rehabil. 2021 Dec 1;67(4):399-408. doi: 10.5606/tftrd.2021.7983. PMID: 35141479; PMCID: PMC8790272.