Cervicogenic dizziness, headaches and visual disturbance are relatively frequent observations in the physiotherapy clinic. The spectrum of pathological possibilities is broad and we have discussed these previously in our whiplash discussions.
I recently had a longstanding patient of mine re-present with a two week history of blurred vision following a heavy fall during a martial arts training. He was wearing protective headgear but landed on the right shoulder with subsequent impact on the head. He did not loose consciousness (due to the chosen nature of his sport was very familiar with that). Without labouring his history he has recurrent episodes of cervicogenic headache, scapular and myofascial symptoms. He also has sacroiliac symptoms all of which are transient in nature. He has the usual cluster of physical signs that one would expect.
He did have an unusual postural alignment of a “laterally displaced” cervical spine. I distinguish this from a “laterally flexed” cervical spine as would be seen in a torticollis or acute radiculopathy. While some of these features were driven from altered pelvic alignment they still persisted in seating when spinal alignment was re-established. He had no structural kyphotic or scoliotic features.
What concerned me more about this more recent episode was he reported a loud clunking sensation in the upper cervical spine. Again I distinguish this from crepitus, which he frequently reported and of course is a feature we all observe clinically frequently. Having seen him through several previous episodes of upper cervical dysfunction (but without dizziness and trauma), I have seen anterior throat symptoms, difficulty in swallowing and hoarseness all of which have been thoroughly investigated without findings. I have been suspicious of some form of subtle instability in this area although I could not diagnose it with any of the currently described upper cervical stability tests – at least not in my hands.
I treated him with a combination of localised upper cervical joint mobilisations, intermittent manual traction and some soft tissue work all in neutral positions, largely as a trial intervention while awaiting the results of a brain scan. I would be strongly suspicious that any of the routine radiological investigations of the cervical spine would not elicit overt instability particularly in the light of this man’s level of athletic function.
Having the advantage of familiarity with a long history over years does allow the clinician the luxury of trial interventions provided they comply with reasonable judgement and are respectful of potential pathology. Of course this is a clinical judgement and unlikely to comply with guidelines!
You maybe interested to know that there is an increasing trend in the U.S. amongst our chiropractic colleagues to use video fluoroscopy for imagining spinal motion and essentially providing a digital motion X-ray of intersegmental motion. The American Medical Association (AMA) produce a series of encyclopaedic guides known as the AMA Guides which categorise pathology and functional impairment. Subtle spinal instability is now recognised and diagnosable using this technology. I am still reaching out to my radiological colleagues to see if there is potential to utilise this within routine clinical practice but it certainly appears to provide an exciting opportunity.
I will keep you posted on the outcome of this case.
It does raise some interesting questions in relation to interpretation of symptoms and matching the physical signs, symptoms and historical accounts.
Do you think I was taking a risk treating this patient without a full diagnostic work up?
Do you think there is a risk of patient familiarity leading us to overlooking serious pathology?
Or conversely, does familiarity give us confidence to progress with treatment of cervicogenic dizziness knowing the patient’s normal response characteristics?
Let us know your thoughts.
Enjoy the clinical challenge.
David.GHTime Code(s): nc
The typical research methodology examining cervical muscle function in neck pain involves strength and endurance testing using various forms of dynamometry devices. Deficits in isometric strength and endurance have been consistently documented for the cervical flexors, the cranio-cervical flexors and the cervical extensor muscles. Importantly, neck pain sufferers exhibit a poorer steadiness of contraction at low load (20% of MVC) compared to controls, which may reflect other muscle fatigue manifestations such as muscle tremor.
In accordance with the general theories of muscle imbalance the theoretical model suggests an impairment of deep cervical muscle function produces a secondary overload in synergic muscles – which appears what we frequently observe clinically. This would appear to correlate with patient subjective reports of difficulty in sustained postures, classically keyboards, reading and driving.
More subtle forms of investigation into muscle function attempt to explore the efficiency of motor control. This relates more specifically to the timing and intensity of synergic muscle function and the appropriateness of activation for a given functional task. One of the fundamental principles of an efficient motor control is the efficiency of motor recruitment whereby there is:
1) minimal extraneous muscle recruitment for the task in hand.
2) optimal force generation specific to the task at hand
3) sequencing of motor unit activation in accordance with the level of demand and
4) deactivation / switching off of the activated groups following execution of the task.
In clinical practice the analyses of these variables is not always possible to explore in depth so we are left extrapolating information from the results of more primitive strength/endurance/alignment/length-tension relationships.
One of the biggest challenges that we face clinically is evaluating the contribution of the axioscapular musculature as a contributory mechanism to cervical pain. This is compounded by the fact that frequently patients report exacerbating activities that involve the simultaneous challenge of the neck and use of the arm i.e. reading, keyboards and driving and therefore the challenge clinically is to determine which mechanism is the dominant driver. The conventional wisdom is to view the most superficial muscles of the posterior neck as prime axio-scapular muscles i.e. trapezius and levator scapula and to evaluate their function in the context of efficiency of scapular/arm control on the basis of a separate intrinsic muscular control system for the neck. This of course is a hypothetical construct (originally discussed in Bergmarks paper postulating local and global muscle function) but one, which seems to have some relevance clinically, at least to provide a guiding framework for intervention.
Because the timescale to improve muscle function both around the neck and the scapular area is likely to extend over weeks rather than days it becomes a management priority to determine the most legitimate target to treat. I find kinesio tape to be of great assistance in this regard because it is straightforward to apply a supportive taping technique to either the cervical spine or scapular and assess the response on the next patient review. This is what the renowned Australian Physiotherapist Bill Vicenzino calls a “treatment direction” test and is very worthwhile applying in the clinical setting.
It is also much easier to achieve patient compliance with specific (often subtle) corrective therapeutic exercise if it can be demonstrated that their symptoms are eased by changing the pattern of muscle activation artificially and therefore provide an incentive to comply with the rehabilitation regime to reinforce this.
Enjoy the clinical challenge.
The International Headache Society originally classified 126 different types of headaches and orofacial pain. In primary care 3 sub-classifications of headaches allow useful patient categorisation.
Tension type headache
Orofacial pain and Bruxism often compound the diagnosis of headache as there maybe overlapping pathophysiology. Exclusion of “red flags” is critical.
Headache “Red Flags”
1) Instantaneous headache
2) Sub-acute headache in patients over 55
3) Neurological signs
5) Neck stiffness
6) Headache worse on wakening
7) Recent head trauma.
Having excluded the red flag categorisations you are then left with the three defining categories as above of migraine, tension type headache and cervicogenic headache.
more likely to be unilateral
Helped by sleep.
Typically occurring episodes lasting between 4-72 hours.
True migraine can be managed by the use of pharmacological agents such as:
These are obviously issues for a prescribing physician or neurologist. The physiotherapist needs to be aware of these therapeutic modalities as often the patient will present with neck pain which is secondary to a primary vascular cause of migraine. Detailed history of the migraine pattern in terms of precipitating factors which maybe well known food substances e.g. chocolate, red wine, dairy products or less frequently dehydration, fatigue, exercise, physical loading, ergonomics and musculoskeletal factors. While these patients may have true vascular migraine, mechanical factors amenable to physiotherapy may also be relevant triggers and thus are legitimate targets for treatment.
Very often a chronic migraineur develops a pattern, persistent tension type headache as part of an ongoing symptom pattern punctuated by episodes of an acute vascular migraine. The ongoing tension headache is often more debilitating and functionally impairing and harder to manage with pharmacological strategies. Typically described as:
Band like pain radiating from the forehead to the occiput
Often involving the neck muscles.
Pathogenesis is unclear at this point. In association with persistent muscle tension the obvious therapeutic strategies of optimising muscle control, improving deep neck flexor function and optimising scapula control are all part of the routine testing protocols which should be addresses if clinically demonstrated. For patients who do not display these deficits there maybe a role for general relaxation or specific biofeedback training. The commonest clinical challenge is to prioritise from a multitude of co-existing findings.
This is frequently under recognised in primary care masquerading under a diagnosis of migraine. Typically these patients describe symptoms, which last longer than an acute migraine episode of 4-72 hours with symptoms often lasting days to weeks. Sleep does not usually influence symptoms and the pain intensity is usually of less severity that an acute migraine attack. There may be some associated sensations of aura mimicking a migraine. These can sometimes be reproduced by cervical provocation testing using manual techniques. Pain is usually localised on one side and frequently periorbital distribution but can also involve the maxillary and mandibular regions. Co-existing TMJ pathology may compound the diagnosis.
TMJ Related Headache
The pain referral pattern from the TMJ may involve the temporal and frontal regions and the myofascial referral zones involve the head, face and neck. The primary issue with TMJ related pain is to establish whether it is driven by Dental issues relating to occlusion and bite mechanics, which require specific intervention from those specialties.
Alternatively, Bruxism (habitual grinding) – both nocturnal and daily are often significant perpetuating factors in the symptom pattern. Treatments that target the TMJ involve specific joint mobilisation, improving general ranges of motion, post-isometric relaxation, general jaw mobilisation and specific myofascial trigger point therapy using either palpatory of dry needling techniques. Dental occlusion splints at night are also typically part of the management strategy.
From a physiotherapy perspective it is common to observe a temporary reduction in clinical signs by treating symptomatic articular / myofascial components but the effects of treatment are relatively short lived. In these situations the challenge is then to explore symptom drivers. The use of kinesio tape is beneficial for evaluating the role of postural alignment as often there is a dual ergonomic and stress / tension component related to occupational factors as part of the symptomatology. These are undoubtedly challenging patients to treat and certainly require multi disciplinary collaborative input in order to optimise management.
Enjoy the clinical challenge
The spectrum of whiplash treatment is a reflection of the diversity of pathology which is encountered and may in turn lead to a variety of clinical manifestations now referred to as whiplash associated disorders (WAD).
The initial guidelines on WAD were formulated in 1996 by the Quebec task force.
This patient group includes:
27% of subjects who still have pain 6 months post injury
15 – 20% of subjects develop persistent pain & disability
$29 Billion – The U.S. annual costs associated with WAD
In general terms treatments involve a combination of:
● Manual Physical Therapy & Graded Exercise
● Deep Neck Flexor Endurance Exercise
● Patient Education on Staying Active
Early referral to Physiotherapy results in superior short and long-term outcomes when compared to immobilization with a soft collar and advice to rest, even in patients with identified elevated psychological distress levels.
Associated mechanical thoracic spine impairments may be more prevalent in patients with WAD (69%) than in those with mechanical neck disorders (13%) and when treated with thoracic manipulation, patients with WAD demonstrate greater reductions in pain than patients with mechanical neck pain.
Retraining the deep cervical flexors in conjunction with manual therapy to the cervicothoracic spine can effectively decrease neck pain and headache with results being maintained at one-year follow-up.
Reassurance that there is no serious tissue damage, encouraging patients to stay active and maintain normal activities of daily living is effective in reducing delayed recovery.
Elevated psychological distress is a nearly uniform finding in patients suffering from acute WAD and is associated with several predictive factors
≥26 pts on the Impact of Events Scale (IES) is indicative of patients with higher levels of post-traumatic stress reaction, adversely affected recovery, and more likely to benefit from specific treatment. In fact, an Neck Disability Index (NDI) score ≥30 combined with cold hyperalgesia results in a 10-fold increase in the odds of experiencing moderate to severe levels of posttraumatic stress.
Higher initial scores on the Neck Disability Index (NDI), older age, cold hyperalgesia and higher acute post-traumatic stress levels accurately are predictive of those who will experience moderate to severe symptoms at 6 months.
Patients with Quebec Task Force WAD Grade I-III as early in the course of care as possible. This would include patients with headaches and non-progressive neurological symptoms
In particular, patients with the following factors should be referred in order to decrease the probability of developing chronic symptoms:
● IES score ≥26 pts
● NDI score ≥30 pts
● Older patients
● Cold Hyperalgesia
The key clinical issues are to determine if a patient has factors predictive of chronicity and the likelihood they would benefit from physiotherapy intervention.
Sterling’s Modified classification (2004)
|WAD 0||No signs|
|WAD 1||Complains of stiffness & tenderness
No physical signs
|WAD 1A||Neck pain, Motor impairments, Reduced ROM, Local Hyperalgesia|
|WAD 1B||As 1A + Psychological distress|
|WAD 1C||As 1B + proprioceptive impairments, diffuse pain pattern, Post – traumatic stress|
|WAD 2||As Quebec|
|WAD 3||As Quebec|
|WAD 3||As Quebec|
The suggested modifications are aimed at selecting sub-groups of patients where more specific whiplash treatment can be devised based on the spectrum of clinical signs and incorporating psychosocial factors and pain mechanisms.
Enjoy the clinical challenge.
Differentiation of the pathogenesis of headaches is a complex clinical challenge. The International Headache Society have classified 126 types of headache on the basis of:
responsiveness to pharmacological intervention.
Many patients are diagnosed as Migraine sufferers but do not fit the classical ” migraine with aura” classification and are then classified as “atypical migraine without aura”.
While many of these patients can identify specific triggers (alcohol, dairy products, chemical irritants, ambient lighting, fatigue and dehydration many are unable to determine triggers.
Unfortunately, many chronic migrainuers develop “Tension type headache” or alternatively “chronic daily headache”
Physiotherapists dealing with this type of caseload commonly find a multitude of clinical signs in the cervical & thoracic spine together with TMJ dysfunction.
The clinical challenge is to determine the relevance of co-existing physical signs and the prioritisation of legitimate targets to treat.
The pain producing structures may be….
Common mechanisms may precipitate sensitisation of these structures
previous musculoskeletal history
and the clinician must prioritise the primary target tissue.
Often this is influenced by clinician bias as to whether they utilise a manual therapy approach, a general exercise regime, a specific muscle imbalance protocol, myofascial techniques or dry needling.
The direction for future research into cervicogenic headaches needs to look at the testing and interpretation of musculoskeletal clinical signs which are frequently associated with headaches in order to establish clinical prediction rules and a clinical efficacy protocol for the management of these challenging patients.
Share your experiences with fellow clinicians by adding your comments below.
Enjoy the clinical challenge