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E56 / The Journal of Manual & Manipulative Therapy, 2006
P
atients complaining of dizziness often pose a di-agnostic challenge because of the varied possibleeitiologies responsible for this symptom. Perhaps mostrelevant to the orthopaedic manual physical therapist isthe fact that dizziness may be of cervical spine origin butthis symptom may also occur as a result of vestibular,cardiovascular, neurological, metabolic, and psychiatriccauses
1
. Because many conditions, both benign andserious, can cause dizziness, comprehensive differentialdiagnosis for a patient complaining of dizziness is notonly difficult but also essential
1
. Huijbregts and Vidal
1
Cervicogenic Dizziness: A Case Report Illustrating OrthopaedicManual and Vestibular Physical Therapy Comanagement
 Address all correspondence and request for reprints to:Ron Schenk Associate ProfessorDoctor of Physical Therapy ProgramOffice DS 317Daemen College4380 Main Street Amherst, NY 14226rschenk@daemen.edu
 Abstract:
The diagnosis and treatment of patients with dizziness of a cervical origin may posea challenge for orthopaedic and vestibular physical therapy specialists. A thorough exami-nation, which consists of a screening examination to rule out pathologies not amenable tosole physical therapy management and, if indicated, a physical therapy differential diagnosticprocess incorporating both cervical spine and vestibular tests and measures, may indicatean appropriate course of management. The treatment progression is then based on patientsigns, symptoms, and response to physical therapy interventions. This case study describesthe diagnosis, treatment, and outcomes of a patient with cervicogenic dizziness co-managedby a vestibular and an orthopaedic manual physical therapist.
 Key Words:
Dizziness, Cervicogenic, Orthopaedic Manual Physical Therapy, Vestibular Physi-cal Therapy
 Ron Schenk PT, PhD, OCS, FAAOMPT, Cert. MDT  Laura B Coons, DPT  Susan E. Bennett PT, EdD, NCS Peter A. Huijbregts, PT, DPT, OCS, FAAOMPT, FCAMT 
recommended the consistent use of a classification systemto assist in the differential diagnosis of dizziness. Theauthors referred to 4 subtypes for classifying complaintsof dizziness: vertigo, presyncope, dysequilibrium, andother dizziness. Table 1 provides an overview of thesefour subtypes and relevant associated pathologies.Cervicogenic dizziness is dizziness attributed to in- volvement of the cervical spine
2,3
. Biesinger
2
and Wrisleyet al
3
suggested that the following symptoms are indica-tive of a diagnosis of cervicogenic dizziness that mayrespond to physical therapy (PT) interventions:•Pain or discomfort in the cervical region, especiallyfollowing trauma•Dizziness that can be provoked by certain headpositions or movements•Dizziness of short duration and decreasingintensity•Persistent occipital region headache•Limited cervical spine range of motion (ROM)•Jaw pain•Upper extremity radicular symptoms
The Journal of Manual & Manipulative Therapy Vol. 14 No. 3 (2006), E56 - E68
 
Cervicogenic Dizziness: A Case Report Illustrating OrthopaedicManual and Vestibular Physical Therapy Comanagement / E57
Three mechanisms have been implicated in theetiology of cervicogenic dizziness
2,4
:•Irritation of the cervical sympathetic nervoussystem•Mechanical compression or stenosis of the vertebralartery•Involvement of the proprioceptors of the uppercervical spine caused by functional disorders in thesegments C0-C3The cervical sympathetic ganglia lie parallel to thespinal cord traversing along blood vessels and musclesantero-lateral to the vertebral bodies. The superior cer- vical ganglion, the largest of the cervical sympatheticganglia and formed by coalescence of the cranial foursympathetic ganglia
5
, is located at the level of C2-C3.Upper cervical dysfunction has been hypothesized tonegatively impact this ganglion
2,4
. This might affectthe sympathetic innervations of both the vertebral andinternal carotid arteries with subsequent posteriorcirculation hypoperfusion resulting in complaints of presyncopal dizziness
5,6
.Mechanical compression, tension, dissection, or stenosisof one or both vertebral arteries as they pass throughthe cervical region will cause decreased blood flow andcan also result in symptoms of presyncopal dizziness.Faulty head and neck posture, congenital deformities of the bones and tissues of the upper cervical spine, andtraumatic or degenerative instabilities are among thecauses of the mechanical compromise that could resultin decreased vertebrobasilar blood flow
1,2,4,7
.Relationships between neck proprioceptors of theupper and lower cervical spine dorsal roots and vestibularnuclei play a role in eye-hand coordination, perceptionof balance, and postural adjustments
3
. Dysequilibriumsubtype dizziness of cervicogenic origin is hypothesizedto result from abnormal afferent input to the vestibu-lar nucleus from damaged joint receptors in the uppercervical region. Clinically, this might be suspected inpatients with cervical spondylosis or after treatment withcervical traction and after trauma to the neck
8
. Cohen
9
 described deficits in balance, orientation, and coordina-tion in primates following injection of anaesthetic in theupper three cervical dorsal roots. Wrisley et al
3
hypoth-esized a role for irritation on the cervical proprioceptorsfrom muscle spasms and trigger points in the etiologyof cervicogenic dizziness. Postural asymmetries of the
Table 1
: Dizziness subtypes and associated pathologies
1
Vertigo Presyncope DysequilibriumOther Dizziness
Benign paroxysmal positional vertigoMenière’s diseaseAcute peripheral vestibulopathyOtosclerosisHead traumaCerebellopontine angle tumor Toxic vestibulopathiesAcoustic neuropathy
Perilymphatic stula
Autoimmune disease of the inner ear Cerebellar drug intoxicationWernicke’s encephalopathy
Inammatory cerebellar disorders
Multiple sclerosisAlcoholic cerebellar degenerationPhenytoin-induced cerebellar degenerationHypothyroidismParaneoplastic cerebellar degenerationHereditary spinocerebellar degenerationsAtaxia-telangiectasiaWilson’s diseaseCreutzfeldt-Jakob diseasePosterior fossa tumorsPosterior fossa malformationsFamilial paroxysmal ataxiaVasovagalpresyncopeCardiovascular presyncopeMigraineTakayasu’s diseaseCarotid sinussyndromeOrthostatichypotensionHyperventilationCough-relatedsyncopeMicturition syncopeGlossopharyngealneuralgiaHypoglycemiaVertebrobasilar 
insufciency
Vertebrobasilar infarctionVertebrobasilar migraineSubclavian stealsyndromeVisual impairmentMyelopathyCervicogenicdizzinessMusculoskeletalimpairmentBasal gangliaimpairmentPanic disorder Phobic posturalvertigoOtolithdysfunction
 
E58 / The Journal of Manual & Manipulative Therapy, 2006
head and neck might create unequal compression andtension on the articulating surfaces of the first three vertebrae, ligaments, and muscles. Faulty posture andmuscle imbalances might also cause decreased ROM andproduce conflicting signals with regard to head positionto the central nervous system (CNS) when it compares vestibular, visual, and cervical input. Both the deep cer- vical flexor muscles and the cervical joint capsules arelined with mechanoreceptors and are hypothesized toplay a role in dizziness if dysfunctional
3
. Brown
10
statedthat with strong connections between the cervical pro-prioceptors and balance function, it is understandablethat injury or pathology of the neck may be associated with a sense of dizziness or dysequilibrium
 .
Because all of these factors may contribute to cervi-cogenic dizziness, orthopaedic manual physical therapy(OMPT) intervention may include stability exercises,postural re-education, stretching of shortened muscles,strengthening of weak muscles, and improvement of cervical spine joint play
2,3,10-12
.
 
In a systematic review of the literature, Reid
 
and Rivett
13
noted that all studies of manual therapy treatment of patients with cervicogenicdizziness reported consistent post-treatment decreases insymptoms and signs of dizziness. Vestibular rehabilita-tion is sometimes a necessary adjunct to the treatmentof patients with dizziness of suspected cervical origin
3
.Several authors have reported successful outcomes whenincorporating vestibular rehabilitation exercises withOMPT in the treatment of patients with cervicogenicdizziness
2,3,12,14
.
 
The literature on PT evaluation and managementof patients with cervicogenic dizziness is limited. Cer- vicogenic dizziness is a diagnosis of exclusion: Whendizziness related to other conditions has been ruledout, dizziness due to either hypomobility or instabilityof the upper cervical spine may be considered
1
. Thisclearly illustrates the need for a screening examinationfor conditions causing dizziness that are not amenableto sole PT management and that, therefore, requirereferral for medical-surgical (co)management. It alsoindicates the need for a PT differential diagnosis inorder to determine both appropriate further tests andsubsequent interventions. The purpose of this case reportis to illustrate OMPT and vestibular physical therapyco-management of a patient complaining of dizzinessof cervical origin.
Case Description
Subject Description and History
The patient in this case report was a 33-year-oldfemale. Her chief complaint was an 18-month history of dizziness, cervical pain, and occipital headache. Severaldifferent physicians had provided varying diagnoses. Aftershe failed to respond to chiropractic management, anophthalmologist diagnosed her with ocular migraines. A neurologist diagnosed two cervical disc herniations. Aneuro-opthalmologist suggested cranio-cervical pain andpossible intermittent compression of one of the vertebralarteries; this specialist provided no clear explanation forthe symptoms but believed they were originating fromthe cervical spine.This patient was referred to PT for dizziness and apersistent occipital headache. The headache was describedas constant (76-100%) and rated 6/10 at rest and 8/10 atits worst (with 10 rated as “the worst possible pain”) onthe numeric pain rating scale (NPRS). The patient ratedthe overall impact of dizziness on function at 3/5 on a6-point numeric rating scale (NRS, where 0 is rated asno impact and 5 as a complete disability). Williamsonand Hoggart
15
reported that the NPRS was a valid, reli-able, and responsive measure appropriate for use in theclinical setting. Childs et al
16
found that a 2-point changeon the NPRS demonstrates a minimum clinically impor-tant difference although this study was of patients withlow-back and not cervical pain. The present authors arenot aware of research investigating reliability, validity,and responsiveness for using a 6-point NRS to measureimpact of dizziness on function.The patient also complained of bilateral tinnitus, a“burning” sensation in the right cervical and bilateralupper trapezius region, numbness in the 4
th
and 5
th
 fingers on the right hand, loss of balance with quickneck movements involving rotation, episodes of blurred vision with overhead reaching, and “silver flashes of light”in her peripheral vision. She reported no personal orfamily history of heart disease, diabetes, cancer, loss of  vision, glaucoma, or ocular surgery. Her major functionallimitations included reaching overhead, inability to workas a cosmetologist, and difficulty sleeping through thenight without awakening due to neck pain.Initial PT intervention had consisted of myofascialrelease and craniosacral therapy. Three months of treat-ment did not decrease symptoms, and the patient wasreferred to another PT facility with a diagnosis of cervicalderangement and cephalalgia.
 
Three treatments of moistheat, ultrasound to both upper trapezius muscles, andmechanical traction were unsuccessful in decreasingcomplaints and the patient was again referred back tothe family physician.
Vestibular Physical Therapy Examination
One week later, the family physician referred thepatient for vestibular rehabilitation to a board-certifiedPT Neurological Clinical Specialist (NCS) with specialtytraining in vestibular rehabilitation at a hospital-basedPT outpatient clinic. At the time of referral, symptoms were unchanged from the time of the first PT referral.Screening by way of history for cardinal signs andsymptoms of vertebral artery ischaemia (including facialparaesthesiae, syncope, dysphagia, dysarthria, dysphonia,and drop attacks) was negative
1
. The authors are not
of 00

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