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.
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.
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.
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.
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
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
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