Chronic neck pain and vertigo: Is a true balance disorder present?

The effect of cervical traction on stabilometric parameters in cervical radiculopathy patients: A randomized crossover study

BACKGROUND

Cervical traction is effective on pain and function in patients with cervical radiculopathy but its effectiveness on balance disorders has not yet been studied.

OBJECTIVE

To evaluate the effect of mechanical intermittent cervical traction (MICT) on stabilometric parameters in patients with cervical radiculopathy.

METHODS

This randomized crossover study assigned 20 patients with cervical radiculopathy to one of the two groups: Group effective traction (ET)/sham traction (ST) (n= 10) treated firstly with ET (traction force of 12 Kg) then with ST (traction force of 2 Kg) with one-week interval and group ST/ET (n= 10) treated invertedly with a ST then ET. Each traction procedure was maintained for 10 minutes twice separated by 5 minutes of rest. Patients were assessed before and immediately after MICT procedure. Main outcome measures were stabilometric parameters: center of pressure, sway area and lateral and anteroposterior displacements using a force platform. Secondary outcome measures were pain intensity, grip strength and dizziness.

RESULTS

ET has provided a significantly greater improvement in both groups and in the total population in terms of stabilometric parameters (p< 0.01), pain intensity, and grip strength (p< 0.05), compared to ST.

CONCLUSION

MICT seems to have an immediate beneficial effect on stabilometric parameters, pain and grip strength in patients with cervical radiculopathy.

Effectiveness of ischemic compression on myofascial trigger points in relieving neck pain: A systematic review and meta-analysis

BACKGROUND

Ischemic compression is widely used to clinically treat neck pain. However, no meta-analysis has been conducted to evaluate the effects of this process on neck pain.

OBJECTIVE

This study aimed to evaluate the effects of ischemic compression on the myofascial trigger points for improving neck pain-related symptoms (mainly pain, joint mobility limitation and function limitation) and to compare ischemic compression with other therapies.

METHODS

Electronic searches were conducted in PubMed, OVID, Web of Science, EBSCO, SCOUPS, Cochrane Library, PEDro, Wanfang, CNKI and Chinese VIP Database in June 2021. Only randomised controlled trials on the effects of ischemic compression on neck pain were included. The major outcomes were pain intensity, pressure pain threshold, pain-related disability and range of motion.

RESULTS

Fifteen studies involving 725 participants were included. Significant differences were observed between ischemic compression and sham/no treatment group in pain intensity, pressure pain threshold and range of motion immediately and in the short term. Significant effect sizes of dry needling were observed over ischemic compression in terms of improving pain intensity (SMD = 0.62; 95% CI: 0.08 to 1.16; P= 0.02), pain-related disability (SMD = 0.68; 95% CI: 0.19 to 1.17; P= 0.007) and range of motion (MD =-2.12; 95% CI: -2.59 to -1.65; P< 0.001) immediately after treatment. Dry needling also showed a significant small effect size for the short-term reduction of pain (SMD = 0.44; 95% CI: 0.04 to 0.85; P= 0.03).

CONCLUSION

Ischemic compression can be recommended in the immediate and short-term pain relief and increase in the pressure pain threshold and range of motion. Dry needling is superior to ischemic compression in relieving pain and improving pain-related disability and range of motion immediately after treatment.

Clinical characteristics and diagnostic aspects of cervicogenic dizziness in patients with chronic dizziness: A cross-sectional study

BACKGROUND AND OBJECTIVES

Chronic dizziness can significantly affect quality of life, but identifying the underlying cause remains challenging. This study focuses on proprioceptive cervicogenic dizziness (CGD) and aims: (1) to compare clinical test results between patients with CGD, dizzy patients without CGD, and healthy controls; and (2) to evaluate the diagnostic value of the clinical tests for CGD in patients with chronic dizziness.

METHODS

Sixty patients with chronic dizziness (18 with CGD and 42 without CGD), and 43 healthy controls underwent clinical tests evaluating neck function (mobility, proprioception, muscle function and disability), balance control, and the presence of visually induced dizziness. Data were analysed through one-way ANOVA, chi-square, independent samples t-test, and logistic regression analyses.

RESULTS

Patients with CGD had significantly more neck pain-related disability (Neck Bournemouth questionnaire (NBQ), p = 0.006), but better static (Static Balance, p = 0.001) and dynamic balance (Tandem Gait, p = 0.049), compared to dizzy patients without CGD. Univariable analyses revealed that increased NBQ (OR 1.05 [1.01; 1.09], p = 0.017), Joint Position Error (JPE) _{after extension} (OR 1.52 [1.00; 2.32], p = 0.050), and Tandem Gait scores (OR 1.09 [1.01; 1.18], p = 0.046) were individually associated with higher odds of having CGD. Their optimal cut-off level (based on the maximum Youden index) had high sensitivity but low specificity for CGD. The multivariable model, including NBQ and Tandem Gait, had fair discriminative ability (AUC = 0.74, 95% CI [0.61; 0.87]).

CONCLUSION

The combined use of the NBQ and Tandem Gait tests had the highest discriminative ability to detect CGD in patients with chronic dizziness.

Combination of Two Manipulative Techniques for the Treatment of Cervicogenic Dizziness: A Randomized Controlled Trial

Cervicogenic dizziness is clinically associated with upper cervical spine dysfunctions. It seems that manual therapy decreases the intensity of dizziness in these subjects, but what happens to pain measured by pressure pain threshold (PPT) has not been studied. Purpose: analyze the short-term effects of combination two manipulation techniques protocol in worst dizziness intensity (wVAS), dizziness and cervical disability, upper cervical spine mobility and mechanosensivity of cervical tissue. Methods: Assessor-blinded randomized controlled trial was developed. A total of 40 patients with cervicogenic dizziness were randomly divided into two groups. The experimental group received three treatments consisting of a functional massage and a manipulation technique, and compared with a control group. The wVAS, dizziness handicap inventory (DHI), neck disability index (NDI), UCS mobility, and PPTs were measured. Measurements were made at the baseline, first follow-up 48 h after intervention and second follow-up 1 month after the intervention. Results: at second follow-up wVAS (p < 0.001), NDI (p < 0.001), DHI (p < 0.001), and upper right trapezius (p < 0.022) and right suboccipital (p < 0.043) PPTs showed a difference between groups in favor of the experimental group. Conclusions: apparently, the proposed intervention protocol decreases the intensity of dizziness and the mechanosensitivity of the cervical tissue and improves the feeling of disability due to neck pain and dizziness.

Masticatory Muscle Thickness and Activity Correlates to Eyeball Length, Intraocular Pressure, Retinal and Choroidal Thickness in Healthy Women versus Women with Myopia

This study aims to examine the correlations between masticatory and neck muscle thickness and activity versus eyeball length, retinal thickness, choroidal thickness, and intraocular pressure in healthy women versus women with myopia. The study group consisted of 21 women aged 24 years and a control group of 19 women (mean age 23 years). For bioelectrical activity analysis within the temporalis anterior, the superficial part of the masseter muscle, the middle part of the sternocleidomastoid muscle, and the anterior belly of the digastric muscle, an eight-channel BioEMG III electromyograph were used. An M-Turbo ultrasound machine was used to analyze masticatory and neck muscle thickness. The eyeball length was examined by IOL Master 500; choroidal and retinal thickness by Optovue Angiovue; and intraocular pressure by Tono-Pen XL. Refractive errors are related to differences in muscle thickness and electromyographic activity. Bioelectrical activity within the temporalis anterior seems to be associated with ocular length, retinal thickness, and choroidal thickness in women with myopia.

Dizziness and physical health are associated with pain in dizzy patients-A cross-sectional study

BACKGROUND AND PURPOSE

Associations between dizziness, health-related quality of life, and musculoskeletal pain have not been systematically explored in patients with vestibular disorders. Such knowledge may be important for choice of treatments. The study objectives were to examine the extent and localization of musculoskeletal pain and explore whether pain was associated with dizziness and health-related quality of life.

METHODS

The cross-sectional study investigated anonymized data from an earlier survey on patients with long-lasting dizziness (>3 months) examined in an oto-rhino-laryngological department. The sample includes patient between 18 and 70 years with Ménière's disease, vestibular schwannoma, benign positional paroxysmal vertigo, vestibular neuritis, non-otogenic dizziness, and cervicogenic dizziness. General musculoskeletal, that is, pain in muscles, tendons, and joints was registered by a yes/no question. A pain drawing registered localization of pain. Multiple binary logistic regression models were used to determine the association between pain and vertigo-balance and autonomic-anxiety related dizziness by the short Vertigo Symptom Scale (VSS) and sub-scales (VSS-V, VSS-A), and between pain and health-related quality of life by the SF-36, mental and physical component summary scale (SF-36 MCS, SF-36 PCS).

RESULTS

The sample consisted of 503 patients, 60.2% were women, the median age was 50 years. General musculoskeletal pain was reported by 72.8% of patients, neck pain by 59.2% and widespread pain by 21.9%. Multiple binary logistic regression models demonstrated that all the pain measures were significantly associated with VSS-V and VSS-A and SF-36 PCS, but not SF-36 MCS.

DISCUSSIONS

Musculoskeletal pain is prevalent in patients with long-lasting dizziness. The strong associations between pain, VSS, and SF-36 PCS could result in a self-sustaining complex condition. The findings imply that in addition to assessing and treating the vestibular symptoms, musculoskeletal symptoms and physical health should be addressed.

Postural and clinical outcomes of sustained natural apophyseal glides treatment in cervicogenic dizziness patients: A randomised controlled trial

OBJECTIVE

To evaluate how self-report and posturographic measures could be affected in patients with cervicogenic dizziness undergoing sustained natural apophyseal glides.

DESIGN

Randomised controlled single-blind study.

SETTING

Tertiary rehabilitation centre.

SUBJECTS

Patients affected by cervicogenic dizziness, diagnosed by applying accepted criteria. Forty-one patients (19 male, 22 female: mean age 44.3 ± 14.8 years) receiving treatment, and 39 patients (18 male, 21 female: mean age 43.8 ± 13.9 years) receiving placebo were included in the study.

INTERVENTIONS

The treatment group underwent sustained natural apophyseal glides, while the placebo was constituted by a detuned laser. Both groups received their interventions six times over 4 weeks.

MAIN MEASURES

Outcomes were tested by means of self-report measures such as perceived dizziness, neck disability, anxiety and depression. Also, cervical range of motion and posturography testing with power spectra frequency were analysed.

RESULTS

When compared to placebo, treated patients demonstrated a significant decrease in perceived dizziness (post-treatment total Dizziness Handicap Inventory score 20.5 ± 5.3 as compared to 26.2 ± 6 baseline), neck disability and pain (Neck Disability Index and Neck Pain Index post-treatment scores 12.5 ± 4.3 and 45.6 ± 15.1, respectively, as compared to baseline scores of 15.1 ± 4.8 and 62.5 ± 14.3), as well as significant improvement in cervical range of motion and some posturographic parameters.

CONCLUSION

Sustained natural apophyseal glides may represent a useful intervention in reaching short-term beneficial effects in patients with cervicogenic dizziness, with respect to self-perceived symptoms, proprioceptive integration and cervical range of motion improvement.

Usefulness of postural sway spectral analysis in the diagnostic route and clinical integration of cervicogenic and vestibular sources of dizziness: A cross-sectional preliminary study

BACKGROUND

Posturography power spectra (PS) implementation has been proven to discriminate between sensory inputs detriment of vestibular and proprioceptive origin.

OBJECTIVE

To deepen the role of posturography testing in the diagnostic route of dizzy conditions, by comparing two groups of patients -93 affected by cervicogenic dizziness (CGD) and 72 by unilateral vestibular hypofunction (UVH) -with a group of 98 age- and gender-matched healthy subjects, serving as control group (CON).

METHODS

All participants underwent otoneurological testing including video head impulse test (vHIT) and posturography testing with PS analysis. They also filled in Dizziness Handicap Inventory (DHI), Tampa Scale for Kinesiophobia and Hospital Anxiety and Depression Scale questionnaires.

RESULTS

UVH and CGD patients were found to have significant increase in vestibular- and proprioceptive-related PS values when compared with CON. Receiver operating characteristic curves found PS values to reliably discriminate both groups from CON. Positive and negative correlations were respectively found between vestibular-/proprioceptive-related PS domain and DHI in both groups and between PS and vHIT scores in UVH patients.

CONCLUSIONS

PS analysis demonstrated to be useful in differentiating CGD and UVH patients each other and when compared to CON, to objectively represent perceived symptoms filled along the DHI scale and to corroborate the rate of vestibular deficit in UVH patients.

Short-term effects of the traction-manipulation protocol in dizziness intensity and disability in cervicogenic dizziness: a randomized controlled trial

PURPOSE

Analyse the short-term effects of traction-manipulation protocol in dizziness and pain intensity and disability, cervical mobility and postural instability.

MATERIALS AND METHODS

Randomized controlled assessor-blind clinical trial. The traction-manipulation protocol was carried out in the intervention group and compared with a control group where the subjects were kept supine. The intervention protocol follows the IFOMPT safety recommendations. Dizziness and pain intensity, Dizziness Handicap Inventory (DHI), cervical mobility and balance were measured after 48 h and a one-month follow-up.

RESULTS

Forty subjects with cervicogenic dizziness were randomly assigned to an intervention or control group. Significant differences were found in favour of the intervention protocol group in: dizziness intensity (p < 0.001; d = 1.31), DHI (p < 0.001; d = 0.76) pain intensity (p < 0.007; d = 0.92), upper cervical flexion (p < 0.032; d = 0.30) and extension (p < 0.012; d = 0.80) at 48 h follow up. At one-month follow up there were significant differences in favour of the intervention group in: dizziness intensity (p < 0.001; d = 0.95), DHI (p < 0.001; d = 0.0.92) pain intensity (p < 0.001; d = 1.38) and upper cervical extension (p < 0.005; d = 0.92). Postural instability improved in mediolateral displacement static with eyes closed (p < 0.032; d = 0.79) and in dynamic with eyes open (p = 0.003; d = 0.55) at one-month follow-up in the intervention group.

CONCLUSION

The traction-manipulation protocol reduces the dizziness and pain intensity, ameliorates disability and improves upper cervical mobility and postural instability.IMPLICATIONS FOR REHABILITATIONThe intervention protocol reduces the dizziness and pain intensity, and improves self-perceived disability in patients with cervicogenic dizziness.Manual therapy improves the cervical range of motion and the postural instability in the cervicogenic dizziness.The intervention protocol follows the safety recommendations of the International Federation of Orthopaedic Manipulative Physical Therapists.

Osteopathic manipulative treatment in individuals with vertigo and somatic dysfunction: a randomized, controlled, comparative feasibility study

Context

There is a paucity of research assessing the efficacy of osteopathic manipulative treatment (OMT) in patients with vertigo.

Objective

To assess the feasibility of conducting a randomized, controlled trial comparing OMT and vestibular rehabilitation therapy (VRT), alone or in combination, in patients with vertigo and somatic dysfunction.

Methods

Volunteers with vertigo who were also diagnosed with somatic dysfunction (SD) were prospectively enrolled in a blinded, randomized, controlled cohort comparative effectiveness study and assigned to 1 of 4 groups: OMT alone, VRT alone, a combination of OMT and VRT (OMT/VRT), or a nonintervention control group. Participants between 18 and 79 years of age were included if they had experienced symptoms of vertigo for at least 3 months' duration, demonstrated somatic dysfunction, and could participate in computerized dynamic posturography (CDP) testing, tolerate manual therapy and exercises, and communicate effectively in English or Spanish. A total of 3 treatments lasting 45 minutes each were administered 1 week apart to each participant. OMT in this study consisted of counterstrain, myofascial release, balanced ligamentous tension, soft tissue, HVLA, and articulatory techniques. Comparisons were made between composite scores (CS) assessed with computerized dynamic posturography (CDP), dizziness handicap inventory (DHI), optometric evaluation, and osteopathic structural examinations collected before the first treatment, after the third/final treatment, and 3 months after the final treatment. (ClinicalTrials.gov number NCT01529151).

Results

A total of 23 patients were included in the study: 7 in the OMT group, 5 in the VRT group, 6 in the OMT/VRT group, and 5 in the control group. The OMT/VRT group demonstrated significant improvement in DHI score (P=0.0284) and CS (P=0.0475) between pre- and 3-month posttreatment measures. For total severity, improvements were significant in the OMT group both from pretreatment to immediate posttreatment measures (P=0.0114) and from pretreatment to 3-month posttreatment measures (P=0.0233). There was a statistical difference between the OMT and control groups from pretreatment to 3-month posttreatment DHI scores (P=0.0332). Also, there was a statistical difference in DHI score between VRT and control from pre- to 3-month posttreatment scores (P=0.0338). OMT/VRT statistically and clinically improved visual acuity in patients' right eyes from pre- to posttreatment (P=0.0325). In all participants, vergence dysfunction was prevalent (5; 21.7%) in addition to vertical heterophoria (15; 65.2%).

Conclusion

A combination of OMT and VRT significantly reduced vertigo and improved balance 3 months after treatment (P<0.05). There was a high prevalence in vergence and vertical heterophoria, which are not typical screening measurements used by physical therapists and physicians to assess vertigo patients. With a small sample size, this study demonstrated the feasibility of an interdisciplinary team evaluating and treating patients with vertigo in a community setting. A larger study is needed to assess the efficacy of OMT/VRT in vertigo patients.

Validity and Reliability of the Satel 40 Hz Stabilometric Force Platform for Measuring Quiet Stance and Dynamic Standing Balance in Healthy Subjects

BACKGROUND

A force platform must have validity and reliability for optimal use. The objective of this study was to analyze the validity and the reliability of the Satel 40 Hz stabilometric force platform.

METHODS

A study of instrumental validity and reliability, involving a cross-sectional correlational and comparative analysis was performed. To determine the validity, four certified weights located on three axes were used and the ability of the stabilometric force platform to detect changes in the position of the different axes was observed. A test-retest was performed to analyze the reliability. Forty-two symptom-free volunteers participated in the study. Assessments were taken in a standing static position and in a dynamic position, with the eyes open and closed. Three measurements were taken and the intra-class correlation coefficient (ICC) was calculated.

RESULTS

The validity increased as the weight increased for all the variables measured in the stabilometric parameters (p < 0.05). The reliability was shown to be good to excellent for the two visual conditions. The positional variables obtained a higher ICC. The variable with the best ICC was the Y mean in OE (ICC 0.874 and a p < 0.001). All the values showed an increase in a dynamic situation.

CONCLUSION

The findings support the reliability and validity of the Satel 40 Hz stabilometric force platform. The platform could be recommended to evaluate static and dynamic standing balance in healthy adult individuals. Guidelines for treatment and the level of quality of stabilometry could be obtained from its use.

Bridging the gap between temporomandibular disorders, static balance impairment and cervicogenic dizziness: Posturographic and clinical outcomes

Several studies have investigated the possible influence of temporomandibular disorders (TMD) on body posture and whether cervical spine disorders, such as cervicogenic dizziness (CGD) could play an additional role in affecting static balance. The purpose of this study was to analyze static postural behavior by means of static posturography, in patients affected by either TMD or CGD alone or by both conditions, and to compare findings with a group of healthy subjects. Significant changes in posturographic parameters were found among the three groups of patients and when compared with controls. When the three study groups were compared to each other, subjects affected by a combination of TMD and CGD showed worse postural performances with respect to subjects affected by CGD or TMD alone. Correlations with self-perceived dizziness, anxiety, depression and jaw functionality, investigated by means of validated questionnaires, were found among all patient groups. These results provide new evidences for the presence of static balance alterations in patients suffering from TMD with and without associated cervical spine impairment, by using a reliable diagnostic technique. Further studies are needed in order to identify any causal relation between these two disorders.

Temporomandibular disorders and cervicogenic dizziness: Relations between cervical range of motion and clinical parameters

OBJECTIVE

To analyze the cervical range of motion (CROM) and clinical parameters in patients affected by myogenous temporomandibular disorders (TMD), cervicogenic dizziness (CGD), both TMD and CGD (TMD/CGD), and a group of healthy subjects (HS).

METHODS

CROM degrees, Dizziness Handicap Inventory (DHI), Tampa Scale for Kinesiophobia (TSK-17), Hospital Anxiety and Depression Scale (HADS), and Jaw Functional Limitation Scale 20 (JFLS-20) scores were compared between 46 TMD patients, 49 CGD subjects, 43 TMD/CGD patients, and 98 HS.

RESULTS

TMD/CGD and CGD patients demonstrated significantly lower CROM degrees and higher DHI, TSK-17, and HADS values when compared to TMD patients. TMD/CGD and TMD patients demonstrated higher JFLS-20 values when compared to CGD and HS. Significant negative correlations were found in TMD/CGD and TMD patients between JFLS-20 and CROM in flexion and extension.

DISCUSSION

Present findings demonstrated a relation between spine movement impairment and TMD.

Association of Cervical Spondylosis With Peripheral Vertigo: A Case-Control Study

OBJECTIVES/HYPOTHESIS

This study aimed to assess the association of prior cervical spondylosis (CS) with peripheral vertigo.

STUDY DESIGN

Case-control study.

METHODS

Data were retrieved from the Taiwan Longitudinal Health Insurance Database. A total of 2,570 patients who were newly diagnosed with peripheral vertigo were identified. We compared them with a 3:1 ratio of propensity score-matched patients, 7,710 comparison patients from the same dataset. We performed multivariate logistic regressions to estimate the odds ratio for prior CS occurrence among peripheral vertigo patients versus controls.

RESULTS

Of 10,280 sample patients, 1,739 (16.92%) patients had CS prior to the index date. A significant difference in prior CS between peripheral vertigo patients and controls (19.49% vs. 16.06%, P < .001) was observed. Logistic regression analysis shows that the odds of prior CS was 1.285 for peripheral vertigo patients versus controls (95% confidence interval [CI]: 1.143-1.446) after adjusting for age, sex, urbanization level, monthly income, geographic region, hyperlipidemia, diabetes, coronary heart disease, hypertension, and asthma. Prior CS with myelopathy was not associated with peripheral vertigo. Stratified analysis by age showed that the odds of CS were highest among patients with peripheral vertigo in the 45- to 64-year-old age group (1.442, 95% CI: 1.215-1.712).

CONCLUSIONS

CS is associated with subsequent peripheral vertigo in the Taiwan population, with higher risk among those aged 45 to 64 years.

LEVEL OF EVIDENCE

2b Laryngoscope, 131:E625-E630, 2021.

Does the C3/4 disc play a role in cervical spondylosis with dizziness? A retrospective study

PURPOSE

To investigate the effect of C3/4 disc degeneration on cervical spondylosis with dizziness (CSD) and to assess the curative effect of anterior cervical decompression and fusion (ACDF) in patients with CSD.

METHOD

Four hundred nineteen patients who underwent ACDF for treatment of myelopathy or radiculopathy were divided into dizziness and non-dizziness group. The visual analog scale (VAS) score and Japanese Orthopaedic Association (JOA) score were used to determine the intensity of dizziness and neurological symptoms, respectively. Cervical disc degeneration was evaluated using Miyazaki's classification system. Some parameters were measured using cervical radiographs. The surgical effects on CSD were compared between surgery with and without C3/4 level. Multivariate logistic regression analysis was used to determine the risk factors for CSD.

RESULTS

The pre-operative incidence of CSD was 33.9%. Women were more likely to develop dizziness than men (p < 0.05), CSD was significantly associated with C3/4 disc degeneration (69.7%, p < 0.001), and smokers were more subject to dizziness (p < 0.05). Regression analysis showed that female (OR = 1.611, p = 0.031), smoking (OR = 1.719, p = 0.032), Miyazaki grade of C3/4 ≥ IV (OR = 2.648, p < 0.001), and instability on C3/4 (OR = 1.672, p = 0.024) were risk factors for CSD. Treatment of CSD by ACDF involving C3/4 was more effective than not involving C3/4 (efficacy rate, 73.2% vs 51.7%, p < 0.05).

CONCLUSION

The CSD is a common clinical manifestation in elderly patients, especially patients with cervical spondylosis at the C3/4 level. Female, smoking, instability on C3/4, and C3/4 Miyazaki grade ≥ IV could be considered significant risk factors for CSD. CSD is more likely to be alleviated by ACDF involving C3/4.

Neck pain associated with clinical symptoms in dizzy patients-A cross-sectional study

OBJECTIVE

Many patients suffer from concurrent neck pain and dizziness. The aim of this study was to describe the clinical symptoms and physical findings in patients with concurrent neck pain and dizziness and to examine whether they differ from patients with dizziness alone.

METHODS

Consecutive patients with dizziness and neck pain were recruited from an ear-nose-throat department and a spine clinic. They were divided into three groups: patients with dizziness only (n = 100), patients with dizziness as their primary complaint and additional neck pain (n = 138) and finally, patients with neck pain as their primary complaint accompanied by additional dizziness (n = 55). The patients filled in questionnaires regarding their symptom quality, time-course, triggers of dizziness and the Vertigo Symptom Scale Short Form. The physical examination included Cervical Range of Motion, American College of Rheumatology (ACR) Tender Points, Cervical Pressure Pain Thresholds and Global Physiotherapy Examination 52-Flexibility.

RESULTS

Both neck pain groups were more likely to have a gradual onset of dizziness symptoms, more light-headedness, visual disturbances, autonomic/anxiety symptoms, decreased cervical range of motion, decreased neck and shoulder flexibility and increased number of ACR tender points compared with patients with dizziness alone. The group having dizziness as their primary complaint and also reporting neck pain had the highest symptom severity and tended to report rocking vertigo and increased neck tenderness. The group with neck pain as their primary complaint was more likely to report headache.

CONCLUSION

Neck pain is associated with certain dizziness characteristics, increased severity of dizziness and increased physical impairment when compared with dizzy patients without neck pain.

Associations between pressure pain threshold in the neck and postural control in patients with dizziness or neck pain - a cross-sectional study

BACKGROUND

It is theorized that neck pain may cause reduced postural control due to the known physiological connection between the receptors in the cervical spine and the vestibular system. The purpose of this study was to examine whether the pressure pain threshold in the neck is associated with postural sway in patients with dizziness or neck pain.

METHODS

Consecutive patients with dizziness (n = 243) and neck pain (n = 129) were recruited from an otorhinolaryngological department and an outpatient spine clinic, respectively. All subjects underwent static posturography. Pressure pain thresholds were measured at four standardized points in the neck, and generalized pain was assessed using the American College of Rheumatology tender points. The relationship between postural sway and pressure pain threshold was analyzed by linear regression, and the covariates included age, sex, and generalized pain.

RESULTS

In the dizzy group, there was a small, inverse relationship between pressure pain thresholds and sway area with eyes closed, after adjusting for age, sex, and generalized pain (bare platform; lower neck, p = 0.002, R2 = 0.068; upper neck, p = 0.038, R2 = 0.047; foam rubber mat; lower neck, p = 0.014, R2 = 0.085). The same inverse relationship was found between pressure pain thresholds in the neck and the Romberg ratio on a bare platform after adjusting for age, sex and generalized pain (upper neck, p = 0.15, R2 = 0.053; lower neck, p = 0.002, R2 = 0.069). Neither of these relationships were present in the neck pain group.

CONCLUSION

Our findings indicate that the pressure pain threshold in the neck is associated with postural sway in patients suffering from dizziness after adjusting for age, sex, and generalized pain, but only with closed eyes. The association was small and should be interpreted with caution.

TRIAL REGISTRATION

Trial registration: Clinicaltrial.gov NCT03531619. Retrospectively registered 22 May 2018.

Diagnostic route of cervicogenic dizziness: usefulness of posturography, objective and subjective testing implementation and their correlation

PURPOSE

To evaluate posturography measurements, and their association with other clinical tests used for cervicogenic dizziness diagnosis, in a cohort of subjects suffering from cervicogenic dizziness, compared with healthy subjects.

MATERIALS AND METHODS

Ninety-three cervicogenic dizziness patients and 98 age- and gender-matched healthy subjects underwent video-Head impulse test, posturography testing, evaluation of cervical spine movements by means of cervical range of motion goniometer and self-report and performance measures, including Dizziness Handicap Inventory, Neck Disability Index, Neck Pain Intensity, Tampa Scale for Kinesiophobia and Hospital Anxiety and Depression Scale.

RESULTS

Cervicogenic dizziness patients demonstrated significant increases in classical posturography parameters (i.e., surface and length) and in power spectra values within middle and high-frequency interval depicting balance control alterations especially due to proprioceptive integration changes. Furthermore, decreases in degrees of cervical range of motion and increases of self-report and performance measures - highlighting significant complaints of subjective feeling of dizziness - were found in these patients when compared with healthy subjects. Multiple correlations were found between posturography testing and cervical range of motion and Dizziness Handicap Inventory as well as between different self-report and performance measures in cervicogenic dizziness patients.

CONCLUSIONS

The implementation of posturography - including power spectra analysis - coupled with appropriate exclusion of other disorders, may represent a useful tool in improving cervicogenic dizziness assessment in terms of cost, time consumption and correlation with other measurements.Implications for rehabilitationUncertainties in diagnostic assessment of cervicogenic dizziness reflect doubts regarding the causes underpinning the symptoms of imbalance, unsteadiness, and disorientation.Posturography measurement is a low-cost, time-sparing technique and its implementations have proven to be useful in detecting significant alterations in body sway during perturbating situations.Implementation of power spectra analysis on posturography testing may represent a useful tool in improving cervicogenic dizziness assessment also in terms of rehabilitative treatment follow-up.

Shi-Style Cervical Mobilizations Versus Massage for Cervical Vertigo: A Multicenter, Randomized, Controlled Clinical Trial

Objectives: Large sample and high-quality evidence to evaluate the preliminary safety of the mobilizations and massage for cervical vertigo are not yet available. Thus, the present study aimed to investigate the comparative effectiveness and preliminary safety of Shi-style cervical mobilizations (SCM) compared with traditional massage (TM) in cervical vertigo patients. Design: A prospective, multicenter, open-label, randomized, controlled clinical trial with a 1:1 allocation ratio. Settings: Five academic medical centers. Subjects: A total of 360 adult patients with a diagnosis of cervical vertigo. Interventions: The patients were randomly allocated to either an SCM (n = 180) or TM (n = 180) group. The patients were treated during six sessions over 2 weeks. The primary outcome was the Dizziness Handicap Inventory (DHI) total scale score, and secondary outcomes included the DHI subscales, Chinese version of the Short-Form 36 Health Survey (CSF-36), and adverse events (AEs). Outcomes were assessed in the short term at 2 weeks, 1 month, and 3 months, and in the intermediate term at 6 months after randomization. Results: Significant changes were observed from the baseline in the DHI total scale and subscales at 2 weeks and 1, 3, and 6 months in both groups (all p < 0.05). However, the differences between the two groups were not significant (all p > 0.05). Furthermore, we noted significant changes from the baseline in SF-36 scores at 2 weeks in both groups (all p < 0.05), whereas CSF-36 scores were not significantly higher in the SCM group (all p > 0.05) compared with the TM group. No serious AEs were reported in either of the two groups. Conclusions: No differences in outcomes were detected between the SCM and TM groups in terms of treatment of cervicogenic dizziness. Efficacy trials are required to determine whether the improvement observed for each treatment was causally related to the interventions.

Clinical characteristics in patients with cervicogenic dizziness: A systematic review

BACKGROUND AND AIMS

Cervicogenic dizziness (CD) is a clinical syndrome of dizziness associated with neck dysfunction. CD represents a considerable diagnostic challenge since dizziness and neck pain are common symptoms with complex and multifactorial etiologies. Both research and clinical work on CD is limited by the lack of accepted diagnostic criteria. The aim of this study was to review clinical studies on CD and to assess current evidence regarding the clinical characteristics of this syndrome.

METHODS

A comprehensive PubMed and MEDLINE search was conducted from the date of inception of the database, with the last search conducted in September 2018. Included studies had to contain operable diagnostic criteria as well as a comparison between patients considered to have CD and a clinical comparison group. Data extracted were clinical outcomes, diagnostic criteria, age, sex, and sample size. Studies were assessed for methodological quality using the Crowe Critical Appraisal Tool.

RESULTS

Out of 2161 screened studies, eight studies comprising 225 patients met the inclusion criteria. Studies were of low to acceptable methodological quality. The most frequent and consistent clinical characteristic in patients classified as having CD, compared with other populations, was reduced posturographic stability. The most consistent diagnostic criteria were based on the concurrence of neck pain with dizziness after exclusion of other possible reasons for dizziness.

CONCLUSION

There are few studies examining clinical characteristics in patients with cervicogenic dizziness. Altered posturography appeared to be the only consistent characteristic used when distinguishing CD from other populations. Diagnostic criteria currently used in research are likely to have low specificity, since they rest on the exclusion of other causes rather than on positive distinctive features. More studies are needed to better understand the clinical interrelations between dizziness and neck pain.

Balance problems and dizziness after neck surgery - associations with pain and health-related quality of life

Introduction: Symptoms of dizziness or imbalance are often present in individuals with a variety of neck-disorders. The aims of this study were to determine the prevalence of patient-reported balance problems and dizziness 10-13 years after surgery for cervical degenerative disc disease; evaluate associations with neck pain and health-related quality of life; and investigate how these individuals described dizziness. Material and methods: Sixty-eight individuals, 10 years or more after anterior cervical decompression and fusion surgery, who previously participated in a randomized controlled trial were included. Participants completed questionnaires including ratings of dizziness and balance problems, the Dizziness Handicap Inventory, and an open-ended question regarding their experience of dizziness. Secondary outcomes were neck pain and quality of life. Results: Seventy-two percent experienced occasional or daily symptoms of unsteadiness and/or dizziness. Intensity ratings for dizziness during movement and for balance problems were similar and rather low, but had an impact on quality of life. Ratings of dizziness at rest were even lower. Dizziness ratings were associated with neck pain. Strenuous activities were related to dizziness and dizziness was primarily described as intermittent and non-rotatory. Conclusions: Dizziness or balance problems in the long-term after surgery for cervical degenerative disc disease are common and have an impact on daily life. Ratings of problem frequency and intensity were usually low. Dizziness and balance problems may affect quality of life. Patients' descriptions of these problems are in line with common symptoms of cervicogenic dizziness.

Approach to cervicogenic dizziness: a comprehensive review of its aetiopathology and management

PURPOSE

Though there is abundant literature on cervicogenic dizziness with at least half a dozen of review articles, the condition remains to be enigmatic for clinicians dealing with the dizzy patients. However, most of these studies have studied the cervicogenic dizziness in general without separating the constitute conditions. Since the aetiopathological mechanism of dizziness varies between these cervicogenic causes, one cannot rely on the universal conclusions of these studies unless the constitute conditions of cervicogenic dizziness are separated and contrasted against each other.

METHODS

This narrative review of recent literature revisits the pathophysiology and the management guidelines of various conditions causing the cervicogenic dizziness, with an objective to formulate a practical algorithm that could be of clinical utility. The structured discussion on each of the causes of the cervicogenic dizziness not only enhances the readers' understanding of the topic in depth but also enables further research by identifying the potential areas of interest and the missing links.

RESULTS

Certain peculiar features of each condition have been discussed with an emphasis on the recent experimental and clinical studies. A simple aetiopathological classification and a sensible management algorithm have been proposed by the author, to enable the identification of the most appropriate underlying cause for the cervicogenic dizziness in any given case. However, further clinical studies are required to validate this algorithm.

CONCLUSIONS

So far, no single clinical study, either epidemiological or interventional, has incorporated and isolated all the constitute conditions of cervicogenic dizziness. There is a need for such studies in the future to validate either the reliability of a clinical test or the efficacy of an intervention in cervicogenic dizziness.

Chiropractic treatment including instrument-assisted manipulation for non-specific dizziness and neck pain in community-dwelling older people: a feasibility randomised sham-controlled trial

Background

Dizziness in older people is a risk factor for falls. Neck pain is associated with dizziness and responds favourably to neck manipulation. However, it is unknown if chiropractic intervention including instrument-assisted manipulation of the neck in older people with neck pain can also improve dizziness.

Methods

This parallel two-arm pilot trial was conducted in Melbourne, Australia over nine months (October 2015 to June 2016). Participants aged 65–85 years, with self-reported chronic neck pain and dizziness, were recruited from the general public through advertisements in local community newspapers and via Facebook. Participants were randomised using a permuted block method to one of two groups: 1) Activator II™-instrument-assisted cervical and thoracic spine manipulation plus a combination of: light massage; mobilisation; range of motion exercises; and home advice about the application of heat, or 2) Sham-Activator II™-instrument-assisted manipulation (set to zero impulse) plus gentle touch of cervical and thoracic spinal regions. Participants were blinded to group allocation. The interventions were delivered weekly for four weeks. Assessments were conducted one week pre- and post-intervention. Clinical outcomes were assessed blindly and included: dizziness (dizziness handicap inventory [DHI]); neck pain (neck disability index [NDI]); self-reported concerns of falling; mood; physical function; and treatment satisfaction. Feasibility outcomes included recruitment rates, compliance with intervention and outcome assessment, study location, success of blinding, costs and harms.

Results

Out of 162 enquiries, 24 participants were screened as eligible and randomised to either the chiropractic (n = 13) or sham (n = 11) intervention group. Compliance was satisfactory with only two participants lost to follow up; thus, post-intervention data for 12 chiropractic intervention and 10 sham intervention participants were analysed. Blinding was similar between groups. Mild harms of increased spinal pain or headaches were reported by 6 participants. Costs amounted to AUD$2635 per participant. The data showed a trend favouring the chiropractic group in terms of clinically-significant improvements in both NDI and DHI scores. Sample sizes of n = 150 or n = 222 for dizziness or neck pain disability as the primary outcome measure, respectively, would be needed for a fully powered trial.

Conclusions

Recruitment of participants in this setting was difficult and expensive. However, a larger trial may be feasible at a specialised dizziness clinic within a rehabilitation setting. Compliance was acceptable and the outcome measures used were well accepted and responsive.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12613000653763. Registered 13 June 2013.

Trial funding: Foundation for Chiropractic Research and Postgraduate Education (Denmark).

Visual, Musculoskeletal, and Balance Complaints in AMD: A Follow-Up Study

Purpose. To investigate whether patients with age-related macular degeneration (AMD) run a potentially higher risk of developing visual, musculoskeletal, and balance complaints than age-matched controls with normal vision. Methods. Visual assessments, self-rated visual function, self-rated visual, musculoskeletal, and balance complaints, and perceived general health were obtained in 37 AMD patients and 18 controls, at baseline and after an average of 3.8 years later. Results. At follow-up both groups reported decreased visual acuity (VA) and visual function, but only AMD patients reported significantly increased visual, musculoskeletal, and balance complaints. Decreased VA, need for larger font size when reading, need for larger magnification, and decreased self-rated visual function were identified as risk markers for increased complaints in AMD patients. These complaints were also identified as risk markers for decreased health. For controls, decreased VA and self-reported visual function were associated with increased visual and balance complaints. Conclusions. Visual deterioration was a risk marker for increased visual, musculoskeletal, balance, and health complaints in AMD patients. Specifically, magnifying visual aids, such as CCTV, were a risk marker for increased complaints in AMD patients. This calls for early and coordinated actions to treat and prevent visual, musculoskeletal, balance, and health complaints in AMD patients.

Biobehavioural analysis of the vestibular system and posture control in patients with cervicogenic dizziness. A cross-sectional study

BACKGROUND

Cervicogenic dizziness is a musculoskeletal disorder mainly characterised by dizziness and disequilibrium associated with neck pain. The pathophysiology is unclear and the neurophysiological basis remains to be ascertained. The aim of this study is to compare the vestibulo-ocular reflex and postural control between patients with cervicogenic dizziness and asymptomatic subjects, and to assess the association between debilitating dizziness and other psychosocial variables.

MATERIALS AND METHODS

A total of 20 patients and 22 asymptomatic subjects were selected. Vestibulo-ocular reflex was assessed by performing the head impulse test. Computerised dynamic posturography was used to evaluate the postural control by means of the sensory organisation test. In addition, subjects self-reported their degree of disability due to dizziness, cervical disability, kinesiophobia, and state of anxiety and depression.

RESULTS

There were no differences in the vestibulo-ocular reflex (P>.05). However, we found differences with a medium-to-large effect size (d>0.60) in variables related to proprioception and visual information integration; the former variable set was related to disability due to dizziness. Disability due to dizziness presents strong-to-moderate associations with cervical disability, kinesiophobia, and anxiety.

CONCLUSION

Our data rule out changes in the vestibular system in cervicogenic dizziness, but they do point to proprioceptive impairment. According to our results, the association between dizziness-related disability and other psychosocial factors in cervicogenic dizziness is very relevant for clinical medicine and for future research projects.

Neurotological Findings at a Health Unit for Adults with Cervicalgia

Introduction The cervical spine is a flexible link between the sensory platform of the skull and torso. The fundamental principle of its operation is due to the balance between muscle strength and flexibility, and any dysfunction of this balance causes neck pain, known as cervicalgia.

Objective The objective of this study is to analyze the most prevalent neurotological findings in adults with neck pain.

Method A cross-sectional study in which 33 adults from 50 to 83 years of age with neck pain were evaluated and underwent the following procedures: anamnesis, as well as ENT, audiological, and vestibular exams.

Results The most evident neurotological symptoms were dizziness (75.7%), tinnitus, neck cracking, tingling in the extremities, and auditory problems (36.3% for each). The most frequently reported clinical symptoms were related to cardiovascular (69.7%), endocrine-metabolic (48.5%), and rheumatic (30.3%) systems. In the audiological assessment, 30 subjects (91.0%) presented hearing impairment in at least one ear, with sensorineural impairment being the most prevalent (88.0%). In the vestibular assessment, there were alterations in 13 subjects (39.0%) found in the caloric test. There was a prevalence of alterations in the peripheral vestibular system with a predominance of irritative peripheral vestibular dysfunction.

Conclusion Neurotological complaints were frequent in this population, verifying the importance of these tests in the dysfunctions of the cervical region or the craniocervical junction.

Head-eye movement control tests in patients with chronic neck pain; inter-observer reliability and discriminative validity

Background

Head-eye movement control deficit is an identified problem in patients with chronic neck pain, particularly in cases of whiplash associated disorders (WAD). To date, there is no evidence concerning the reliability and validity of visually assessed active head-eye movement control tests. Therefore, the objectives of the present cross-sectional study were, a) to develop a test battery; and b) to investigate inter-observer reliability and discriminative validity in patients with chronic neck pain compared to healthy controls.

Methods

The study was conducted at two physiotherapy clinics in Switzerland. Ethics Committee approval was obtained. Ten active head-eye coordination tests, on 23 patients with chronic neck pain and associated symptoms and 19 healthy controls, were videotaped. The tests included eye movements in the neutral head position and 45° relative neck rotation, gaze stability and sequential head-eye movements. All tests were performed in the sitting and standing positions. Two blinded physiotherapists independently rated the randomized videos. Performance was rated as "negative", "moderately positive" or "clearly positive". Weighted kappa (wK) and 95% confidence intervals (CI) were calculated to investigate inter-observer reliability. Good reliability was defined as wK >0.5 with a lower boundary of 95% CI >0.2. Odds ratios (to define cut-off points) and the distribution of the classificator, numbers of positive tests, were calculated.

Results

Three out of ten tests showed "excellent" (wK 0.82 to 0.86), five out of ten tests showed "substantial" (wK 0.69 to 0.79) and two out of ten tests showed "moderate" (wK 0.54 to 0.59) reliability. Results were comparable in the sitting and standing positions. On average, three out of five tests were rated positive in patients and one out of five tests was rated positive in healthy controls. An odds ratio of 13.3 to 18.6 was obtained using ≥2/5 tests as a cut-off point.

Conclusion

Visual assessment by physiotherapists of head-eye movement control tests is reliable. The test battery is able to discriminate between patients with chronic neck pain and healthy controls. There were no differences in performance between the sitting and standing positions. The test battery can therefore be reduced to five tests. Further research is needed to identify the test-retest stability and responsiveness.

Objective evaluation of neck muscle tension and static balance in patients with chronic dizziness

CONCLUSION

Increase in the average value of bilateral neck muscle tension (ANT) indicates the increase in neck muscle tension to stabilize static posture resulting from vestibular compensation. Asymmetry of neck muscle tension was closely related to postural imbalance.

OBJECTIVE

Patients with dizziness often complain of neck symptoms with stiff neck. This study was conducted to clarify the pathophysiological mechanism of neck symptoms in patients with dizziness.

METHODS

We objectively measured bilateral trapezius muscle tension in patients with chronic dizziness and determined its relationship with static postural perturbation. The study included 26 patients with chronic dizziness caused by unilateral vestibular deficit and 24 healthy controls. The tension of bilateral trapezius muscles was objectively measured using a neck muscle tension meter. ANT and the ratio (right/left) of the bilateral neck muscle tension (RNT) were calculated. Static posturography was performed to measure total length of path (LNG).

RESULTS

ANT was negatively correlated to LNG under the eyes closed (EC) condition only in the case of the patients (r = -0.44, p < 0.05). In the case of both the controls and the patients with a unilateral vestibular deficit, RNT was positively correlated to LNG under the EC condition.

Standing balance in patients with whiplash-associated neck pain and idiopathic neck pain when compared with asymptomatic participants: A systematic review

Neck proprioception is one of the information sources that helps regulate postural balance. However, it is believed to be impaired as patients with both idiopathic neck pain (INP) and whiplash-associated disorders (WAD) have been shown to have a more unstable balance than healthy controls. This systematic review aims to determine if there are significant differences in balance between patients with INP and healthy controls and between patients with WAD and healthy controls. Studies were sought from PubMed, Cinahl, Physiotherapy Evidence Database, Web of Science, Academic Search Complete, Science Direct, and Scielo. Two reviewers independently screened titles and abstracts, assessed full reports for potentially eligible studies, and extracted information on participants' characteristics, pain characteristics, study methods, study results, and study quality. Twelve studies were included in this systematic review. Of these, six compared INP and healthy controls and eight compared WAD and healthy controls. All but one study (11/12) found a statistically significant difference for at least one measurement between patients with INP and WAD and healthy controls. The results of this systematic review suggest that both patients with INP and patients with WAD have poorer balance than healthy controls.