Cervical vertigo

Short-Term Benefits from Manual Therapy as an Adjunct Treatment for Persistent Postural-Perceptual Dizziness Symptoms: A Preliminary Prospective Case Series

Persistent dizziness and balance deficits are common, often with unknown etiology. Persistent Postural-Perceptual Dizziness (3PD) is a relatively new diagnosis with symptoms that may include dizziness, unsteadiness, or non-vertiginous dizziness and be persistent the majority of time over a minimum of 90 days. The purpose of this case series was to investigate short-term outcomes of reducing dizziness symptoms using a manual therapy intervention focused on restoring mobility in the fascia using a pragmatically applied biomechanical approach, the Fascial Manipulation® method (FM®), in patients with 3PD. The preliminary prospective case series consisted of twelve (n = 12) patients with persistent complaints of dizziness who received systematic application of manual therapy to improve fascial mobility after previously receiving vestibular rehabilitation. The manual therapy consisted of strategic assessment and palpation based on the model proposed in the FM® Stecco Method. This model utilizes tangential oscillations directed toward the deep fascia at strategic points. Six males (n = 6) and females (n = 6) were included with a mean age of 68.3 ± 19.3 years. The average number of interventions was 4.5 ± 0.5. Nonparametric paired sample t-tests were performed. Significant improvements were observed toward the resolution of symptoms and improved outcomes. The metrics included the Dizziness Handicap Inventory and static and dynamic balance measures. The Dizziness Handicap Inventory scores decreased (i.e., improved) by 43.6 points (z = -3.1 and p = 0.002). The timed up and go scores decreased (i.e., improved) by 3.2 s (z = -2.8 and p = 0.005). The tandem left increased (i.e., improved) by 8.7 s (z = 2.8 and p = 0.005) and the tandem right increased (i.e., improved) by 7.5 s (z = 2.8 and p = 0.005). Four to five manual therapy treatment sessions appear to be effective for short-term improvements in dizziness complaints and balance in those with 3PD. These results should be interpreted with caution as future research using rigorous methods and a control group must be conducted.

Risk of Cervical Dizziness in Patients With Cervical Spondylosis

Importance

The dizziness associated with cervical spondylosis is a controversial topic given that many experts believe that cervical spondylosis is a common cause of dizziness, whereas others do not believe it exists.

Objective

To compare the risk of dizziness between patients with cervical spondylosis and matched controls (ie, patients with lumbar spondylosis after propensity score matching [PSM]).

Design, Setting, and Participants

This cohort study used medical claims data from the National Health Insurance Research Database of Taiwan for patients 60 years or older with cervical or lumbar spondylosis newly diagnosed in any outpatient department between January 1, 2010, and December 31, 2015. Patients diagnosed with cervical spondylosis were included as the study cohort, and those diagnosed with lumbar spondylosis who were matched to the study cohort via PSM were selected as the control cohort. Both cohorts were followed up for 1 year unless they were diagnosed with dizziness, censored by death, or withdrew from the health insurance program. Data analysis was performed from August 9 to September 20, 2022.

Main Outcomes and Measures

The main outcome was the date of outpatient diagnosis of dizziness. The risks of dizziness were compared between groups. The relative risk and incidence rate difference were calculated.

Results

A total of 3638 patients with cervical spondylosis (mean [SD] age, 67.9 [7.1] years; 2024 [55.6%] male) and 3638 patients with lumbar spondylosis (mean [SD] age, 68.0 [7.1] years; 2024 [55.6%] male) after PSM were selected as the study and control cohorts, respectively. The patients with cervical spondylosis had higher risk of dizziness than matched controls, with a 1-year relative risk of 1.20 (95% CI, 1.03-1.39). The 1-year incidence of dizziness was 10.2% (95% CI, 9.2%-11.2%) in patients with cervical spondylosis and 8.6% (95% CI, 7.7%-9.5%) in the matched group of lumbar spondylosis. The incidence rate difference between the groups was 1.6% (95% CI, 0.3%-3.0%).

Conclusions and Relevance

These data support the association between dizziness and cervical spondylosis, but the small difference between groups reveals that dizziness associated with cervical spondylosis is uncommon. Clinicians should be wary of diagnosing a cervical cause for dizziness based on an actual history of cervical spondylosis.

Romberg Neck Torsion :A New Specific Test for Cervicogenic Dizziness

AIMS

Previous studies have shown that Cervical myofascial pain syndrome with dizziness (CMPS-D ) is one of the most common causes of cervicogenic dizziness and is associated with challenge in diagnosis and treatment. this study aimed to investigate the Romberg neck torsion test in patients with CMPS-D and healthy controls.

MATERIALS AND METHODS

Cross-sectional, observational study. twenty patients with CMPS-D were compared with twenty healthy controls. the Romberg (neutral position and neck torsion) and smooth pursuit neck torsion tests were performed in patients with CMPS-D and healthy controls.

RESULTS

The results confirmed that there are significant differences in the Romberg neck torsion test between subjects with CMPS-D and healthy controls (p < 0.05). in addition, There was a significant correlation between Romberg neck torsion and smooth pursuit neck torsion results (p < 0.05).

CONCLUSION

The results of Romberg neck torsion test in CMPS-D subjects were different from those in healthy controls, which was attributed to neck pain and changes in cervical proprioception input. Romberg neck torsion is a new method for assessing cervicogenic dizziness.

Audiovestibular Findings in a Cohort of Patients with Chiari Malformation Type I and Dizziness

Chiari Malformation Type I (CM1) is a neurological condition in which the cerebellar tonsils extend past the foramen magnum. While many studies have reported dizziness symptoms in patients with CM1, the prevalence of peripheral labyrinthine lesions is largely unknown. This study aimed to comprehensively describe the audiovestibular phenotype in a cohort of patients with CM1 expressly referred for dizziness. Twenty-four patients with CM1 and a complaint of dizziness/vertigo were evaluated. Hearing and auditory brainstem tract function were essentially normal. While vestibular abnormalities were most prevalent during rotational testing (33%), abnormal functional balance was the most common finding (40%). Patients with CM1 had a greater likelihood of exhibiting an abnormal sensory organization test (SOT) postural stability score for fixed platform conditions, and for the somatosensory analysis score. While no significant associations were identified between tonsillar ectopia extent and any vestibular/balance outcome measure, a significant negative association was identified between neck pain and the somatosensory sensory analysis score. Abnormal functional balance in the somatosensory domain was remarkable, with poorer scores associated with neck pain. An isolated peripheral vestibulopathy was present in only 8% of patients. Despite the low prevalence of vestibulopathy, vestibular/balance assessment is warranted to identify patients who may benefit from referral to specialized medical disciplines.

Oral splint therapy in patients with Menière's disease and temporomandibular disorder: a long-term, controlled study

PURPOSE

To assess the effect of oral splint therapy on audio-vestibular symptoms in patients with Menière's disease (MD) and temporomandibular disorder (TMD).

METHODS

Retrospective case-control study. Treatment group: 37 patients with MD and TMD who received gnatological treatment.

CONTROL GROUP

26 patients with MD and TMD who had never received gnatological treatment. The number of vertigo spells in 6 months (primary endpoint), pure-tone audiometry average (PTA), MD stage, functional level, Dizziness handicap Index (DHI), Tinnitus handicap Index (THI) and Aural Fullness Scale (AFS) were compared at baseline and after 24 months according to groups. Analysis of Covariance was used to determine the treatment effect.

RESULTS

Groups were comparable for demographic, clinical data, baseline PTAs and the number of vertigo spells. Analysis of covariance showed a significant effect of gnathological treatment on number of vertigo spells ([Formula: see text] = 0.258, p < 0.001), PTA ([Formula: see text] = 0.201, p < 0.001), MD stage ([Formula: see text] = 0.224, p < 0.001), functional level ([Formula: see text] = 0.424, p < 0.001), DHI ([Formula: see text] = 0.421, p < 0.001), THI ([Formula: see text] = 0.183, p < 0.001), but not for AFS ([Formula: see text] = 0.005, p = 0.582). The treatment group showed vertigo control of class A in 86.5% and class B in 13.5% of patients. In the control group, vertigo control was of class A in 19.2% of patients and class B in 11.5%, class C in 30.8%, class D in 11.5%, class E in 19.2% and class F in 7.7%. Classes of vertigo control differed significantly (X² test, p < 0.001).

CONCLUSIONS

Oral splint therapy could represent a viable treatment in patients with TMD and uncontrolled MD disease. The effects are maintained at least after 2 years.

Proprioceptive Cervicogenic Dizziness Care Trajectories in Patient Subpopulations: A Scoping Review

Proprioceptive cervicogenic dizziness (PCGD) is the most prevalent subcategory of cervicogenic dizziness. There is considerable confusion regarding this clinical syndrome's differential diagnosis, evaluation, and treatment strategy. Our objectives were to conduct a systematic search to map out characteristics of the literature and of potential subpopulations of PCGD, and to classify accordingly the knowledge contained in the literature regarding interventions, outcomes and diagnosis. A Joanna Briggs Institute methodology-informed scoping review of the French, English, Spanish, Portuguese and Italian literature from January 2000 to June 2021 was undertaken on PsycInfo, Medline (Ovid), Embase (Ovid), All EBM Reviews (Ovid), CINAHL (Ebsco), Web of Science and Scopus databases. All pertinent randomized control trials, case studies, literature reviews, meta-analyses, and observational studies were retrieved. Evidence-charting methods were executed by two independent researchers at each stage of the scoping review. The search yielded 156 articles. Based on the potential etiology of the clinical syndrome, the analysis identified four main subpopulations of PCGD: chronic cervicalgia, traumatic, degenerative cervical disease, and occupational. The three most commonly occurring differential diagnosis categories are central causes, benign paroxysmal positional vertigo and otologic pathologies. The four most cited measures of change were the dizziness handicap inventory, visual analog scale for neck pain, cervical range of motion, and posturography. Across subpopulations, exercise therapy and manual therapy are the most commonly encountered interventions in the literature. PCGD patients have heterogeneous etiologies which can impact their care trajectory. Adapted care trajectories should be used for the different subpopulations by optimizing differential diagnosis, treatment, and evaluation of outcomes.

The efficacy of self-exercise in a patient with cervicogenic dizziness: A randomized controlled trial

Background

Cervicogenic dizziness is a clinical syndrome characterized by neck pain and dizziness. Recent evidence suggested that self-exercise could improve a patient's symptoms. The objective of this study was to evaluate the efficacy of self-exercise as an add-on therapy in patients with non-traumatic cervicogenic dizziness.

Methods

Patients with non-traumatic cervicogenic dizziness were randomly assigned to the self-exercise and control groups. The self-exercise group was instructed to perform muscle, mobilization, and oculomotor training at home while there was no specific training given to the control group. The neck pain, dizziness symptoms, and their impact on daily life were evaluated by the Dizziness Handicap Inventory (DHI) scale, the Neck Disability Index (NDI) scale, and the visual analog scale (VAS). The objective outcomes included the range of motion test of the neck and the posturography test. All outcomes were evaluated at 2 weeks after the initial treatment.

Results

A total of 32 patients participated in this study. The average age of the participants was 48 years. The DHI score of the self-exercise group after the treatment was significantly lower when compared to the control group [mean difference (MD) 25.92 points, 95% CI 4.21-47.63, p = 0.021]. The NDI score after treatment was also significantly lower in the self-exercise group (MD 6.16 points, 95% CI 0.42-11.88, p = 0.036). However, there was no statistical difference in the VAS score, the range of motion test, and the posturography test between the two groups (p > 0.05). No significant side effects were noted in either of the groups.

Conclusion

Self-exercise is effective in reducing dizziness symptoms and its impact on daily life in patients with non-traumatic cervicogenic dizziness.

Vestibular Evoked Myogenic Potentials in Cervical Myofascial Pain Syndrome

Cervical myofascial pain syndrome with dizziness (CMPS-D) has always faced the challenges of evaluation, diagnosis, and etiology. Vestibular-evoked myogenic potentials (VEMPs) are applicable to evaluate the functions of the vestibular system, especially the saccule. The Sound evoked triceps myogenic potentials (SETMPs) have different anatomical efferent connections from Sternocleidomastoid (SCM)-VEMPs. The present study aimed to evaluate the SETMPs and SCMVEMPs in CMPS-D group and compare the results with the control group. We tested 15 participants with CMPS-D with 15 participants in the control group using SCMVEMP and SETMP tests. All participants had normal hearing and vestibular functions. The SCMVEMP response was absent in 4 of 15 patients with CMPS-D, and the mean response CMPS-D group was significantly lower than the control group. There were the SETMP and SCMVEMP responses in all participants in the control group. In CMPS-D subjects with false absent SCMVEMP response, SETMP tests are suitable alternatives for the saccule evaluation, and diminished SCMVEMP in the CMPS-D subjects may not necessarily mean the saccular injury. Furthermore, the involvement of spinal cord pathways is not a cause of dizziness in CMPS-D patients.

Proprioceptive Cervicogenic Dizziness: A Narrative Review of Pathogenesis, Diagnosis, and Treatment

Basic science and clinical evidence suggest that cervical spine disorders can lead to dizziness. The cervical spine has highly developed proprioceptive receptors, whose input information is integrated with the visual and vestibular systems in the central nervous system, acting on the neck and eye muscles to maintain the coordinative motion of the head, eyes, neck, and body through various reflex activities. When the cervical proprioceptive input changes due to the mismatch or conflict between vestibular, visual, and proprioceptive inputs, cervicogenic dizziness may occur. The diagnosis of cervicogenic dizziness can be determined based on clinical features, diagnostic tests, and the exclusion of other possible sources of dizziness. The cervical torsion test appears to be the best diagnostic method for cervicogenic dizziness. Based on the available evidence, we first developed the diagnostic criteria for cervicogenic dizziness. Treatment for cervicogenic dizziness is similar to that for neck pain, and manual therapy is most widely recommended.

A Holistic Approach to a Dizzy Patient: A Practical Update

Dizziness is one of the most common symptoms encountered by physicians daily. It is divided into four categories: vertigo, disequilibrium, presyncope, and psychogenic dizziness. It is essential to distinguish these four symptoms because the causes, prognosis, and treatment differ. Vertigo constitutes a disease of the central or peripheral nervous system. Central origin vertigo may be a life-threatening situation and must be detected as soon as possible because it includes diseases such as stroke, hemorrhage, tumors, and multiple sclerosis. Peripheral origin vertigo includes benign diseases, which may be fully treatable such as vestibular migraine, benign paroxysmal positional vertigo, vestibular neuritis, Ménière’s disease, and cervical vertigo. The HINTS (head impulse, nystagmus, test of skew) examination is essential to distinguish central from peripheral causes. A detailed history including the duration of vertigo (episodic or continuous), its trigger, and a clinical examination step by step following the appropriate protocol could help to make a definite and accurate diagnosis and treatment. Due to a lack of expertise in dizziness and inappropriate treatment, many patients are admitted to dizziness clinics with long-standing dizziness. A holistic treatment combining medications, vestibular rehabilitation, physiotherapy, and psychotherapy should be initiated to improve the quality of life of these patients. So, this review aims to recommend a clinical protocol for approaching a dizzy patient with vertigo and to present in detail the epidemiology, pathophysiology, symptoms, diagnosis, and contemporary treatments of all causes of vertigo.

The Significance of Pain Drawing as a Screening Tool for Cervicogenic Headache and Associated Symptoms in Chronic Fatigue

Purpose

Patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) present with a broad spectrum of symptoms, including headache. A simple, yet powerful tool – the pain drawing identifies essential aspects such as pain distribution. The aim with this study was to 1) evaluate the significance of pain drawing as a screening tool for cervicogenic headache using a predefined C2 pain pattern, 2) assess whether there was an association between dizziness/imbalance and a C2 pain pattern, and 3) compare subgroups according to the pain drawing with respect to pain characteristics and quality of life.

Patients and Methods

Pain drawings and clinical data from 275 patients investigated for ME/CFS were stratified into: 1) cervicogenic headache as determined by a C2 pain pattern, 2) headache with no C2 pain pattern, and 3) no headache. For inference logistic regression presented with odds ratios (OR) and 95% confidence intervals (95% CI) and Kruskal–Wallis test were applied.

Results

One hundred sixteen participants (42%) were stratified to the group for which the pain drawing corresponded to the C2 pain pattern, thus indicating putative cervicogenic origin of the headache. Dizziness/imbalance was strongly associated with a C2 pain pattern; OR 6.50 ([95% CI 2.42–17.40] p ˂ 0.00), whereas this association was non-significant for patients with headache and no C2 pain pattern. Those demonstrating a C2 pain pattern reported significantly higher pain intensity (p = 0.00) and greater pain extent (p = 0.00) than the other groups, and lower health-related quality of life (p = 0.00) than the group with no headache.

Conclusion

For patients with chronic fatigue who present with a C2 pain pattern (interpreted as cervicogenic headache) the pain drawing seems applicable as a screening tool for signs associated with neuropathic and more severe pain, dizziness and reduced quality of life as detection of these symptoms is essential for targeted treatment.

Responses to the Dix-Hallpike test in primary care: A comparison between subjective and objective benign paroxysmal positional vertigo

Patients who experience both vertigo and nystagmus in the Dix-Hallpike test (DHT) are diagnosed with objective benign paroxysmal positional vertigo (BPPV). This test provokes only vertigo in between 11% and 48% of patients, who are diagnosed with subjective BPPV. Detection of nystagmus has important diagnostic and prognostic implications. To compare the characteristics of patients diagnosed with objective and subjective BPPV in primary care. Cross-sectional descriptive study. Two urban primary care centers. Adults (≥18 years) diagnosed with objective or subjective BPPV between November 2012 and January 2015. DHT results (vertigo or vertigo plus nystagmus; dependent variable: nistagmus as response to DHT), age, sex, time since onset, previous vertigo episodes, self-reported vertigo severity (Likert scale, 0-10), comorbidities (recent viral infection, traumatic brain injury, headache, anxiety/depression, hypertension, diabetes mellitus, dyslipidemia, cardiovascular disease, altered thyroid function, osteoporosis, cervical spondylosis, neck pain). In total, 134 patients (76.1% women) with a mean age of 52 years were included; 59.71% had subjective BPPV. Objective BPPV was significantly associated with hypertension, antihypertensive therapy, and cervical spondylosis in the bivariate analysis and with cervical spondylosis (OR=3.94, p=0.021) and antihypertensive therapy (OR 3.02, p=0.028) in the multivariate analysis. Patients with subjective BPPV were more likely to be taking benzodiazepines [OR 0.24, p=0.023]. The prevalence of subjective BPPV was higher than expected. Cervical spondylosis and hypertensive therapy were associated with objective BPPV, while benzodiazepines were associated with subjective BPPV.

The Enduring Controversy of Cervicogenic Vertigo, and Its Place among Positional Vertigo Syndromes

The idea of cervicogenic vertigo (CV) was proposed nearly a century ago, yet despite considerable scrutiny and research, little progress has been made in clarifying the underlying mechanism of the disease, developing a confirmatory diagnostic test, or devising an appropriately targeted treatment. Given the history of this idea, we offer a review geared towards understanding why so many attempts at clarifying it have failed, with specific comments regarding how CV fits into the broader landscape of positional vertigo syndromes, what a successful diagnostic test might require, and some practical advice on how to approach this in the absence of a diagnostic test.

Dizziness and localized pain are often concurrent in patients with balance or psychological disorders

Background and aims Symptoms of dizziness and pain are both common complaints and the two symptoms often seem to coincide. When symptoms appear concomitant for sustained periods of time the symptoms might maintain and even exacerbate each other, sometimes leading to psychological distress. In order to evaluate such comorbidity we studied patients referred to a vestibular unit and to a psychiatric outpatient clinic with respectively balance disorders and psychological issues. Methods Consecutive patients referred to a vestibular unit (n = 49) and a psychiatric outpatient clinic (n = 62) answered the Dizziness Handicap Inventory (DHI) questionnaire and a questionnaire detailing occurrence of dizziness and pain. Results The experience of dizziness and pain often coincided within individuals across both clinical populations, especially if the pain was located to the neck/shoulder or the back (p = 0.006). Patients who reported dizziness had significantly more often pain (p = 0.024); in the head (p = 0.002), neck/shoulders (p = 0.003) and feet (p = 0.043). Moreover, patients who reported dizziness stated significantly higher scoring on emotional (p < 0.001) and functional (p < 0.001) DHI sub-scales. Furthermore, patients who reported an accident in their history suffered significantly more often from dizziness (p = 0.039) and pain (p < 0.001); in the head (p < 0.001), neck/shoulders (p < 0.001) and arms (p = 0.045) and they scored higher on the emotional (p = 0.004) and functional (p = 0.002) DHI sub-scales. Conclusions The findings suggest comorbidity to exist between dizziness and neck/shoulder or back pain in patients seeking health care for balance disorders or psychological issues. Patients suffering from dizziness and pain, or with both symptoms, also reported higher emotional and functional strain. Thus, healthcare professionals should consider comorbidity when determining diagnosis and consequent measures. Implications Clinicians need to have a broader "receptive scope" in both history and clinical examinations, and ask for all symptoms. Although the patients in this study visited a vestibular unit respectively a psychological clinic, they commonly reported pain conditions when explicitly asked for this symptom. A multimodal approach is thus to favor, especially when the symptoms persist, for the best clinical management.

Atypical Symptoms of Cervical Spondylosis: Is Anterior Cervical Discectomy and Fusion Useful? - An Institutional Experience

Background

A significant proportion of patients with cervical spondylosis can present with atypical symptoms like vertigo, tinnitus, nausea, vomiting, headache, blurred vison, palpitations and gastrointestinal (GI) discomfort. The role of ACDF in alleviating these atypical symptoms remains unexplored.

Objective

The current study attempts to investigate the role of anterior cervical discectomy and fusion (ACDF) in alleviating atypical symptoms associated with cervical spondylosis.

Materials and Methods

The patients with cervical spondylosis who underwent ACDF between January 2011 and December 2015 were contacted by phone. Data regarding the severity and frequency of atypical symptoms was collected by a structured questionnaire. Wilcoxon signed rank test was used to compare the severity and frequency of these symptoms before the surgery and at last follow up.

Results

A total of 467 patients underwent ACDF for cervical spondylosis between January 2011 and December 2015, of which 358 patients were interviewed telephonically. 99 of 358 (27.65%) patients who met the eligibility criteria were included in the final analysis. The severity and frequency of vertigo, headache, nausea, vomiting and GI discomfort significantly improved at last follow-up (P < 0.001) compared to pre-operative period. Significant improvement in hypertension was also seen (P = 0.001). Improvements in severity and frequency of tinnitus (P = 0.083), palpitation (P = 0.317) and blurring of vision (P = 1.00) were not significant.

Conclusions

ACDF might improve the atypical symptoms like vertigo, headache, nausea, vomiting and GI discomfort in patients with cervical spondylosis. Some patients also show improvement in hypertension following surgery.

[Less common, but clinically important episodic vertigo syndromes]

Die Differentialdiagnostik der selteneren, episodischen Schwindelsyndrome kann im klinischen Alltag eine Herausforderung darstellen, insbesondere wenn sie keine im Intervall messbaren Befunde in der neuro-ophthalmologischen oder -otologischen Routinediagnostik hinterlassen. Ursächlich für diese episodischen Schwindelsyndrome können physiologische Reaktionen aufgrund intersensorischer Inkongruenzen oder angeborene bzw. erworbene neuroanatomische/neurophysiologische Varianten sein, die zu vestibulären Reizsyndromen führen. In dieser Übersicht fokussieren wir auf die folgenden, aus unserer Sicht wichtigen vestibulären Syndrome: Bewegungskrankheit, Mal de Debarquement Syndrom, Visuelle Höhenintoleranz, Vestibularisparoxysmie, Zervikaler Schwindel, Episodische Ataxie Typ II und Syndrome eines dritten mobilen Fensters wie das Syndrom der Dehiszenz des superioren Bogengangs. Die Ausprägung reicht von milden Symptomen mit geringer Belastung bis hin zu schweren Krankheitsbildern mit relevanter Alltagseinschränkung. Sie können vom Kindes- oder Jugendalter bis ins Senium auftreten, teilweise mit abweichender Symptomatik. Durch gezielte Anamnese und ggf. erweiterte vestibuläre Diagnostik in einem spezialisierten Zentrum lassen sich diese Syndrome oft klar herausarbeiten und einer erfolgreichen Therapie zuführen.

Cervical Proprioception Impairment in Neck Pain-Pathophysiology, Clinical Evaluation, and Management: A Narrative Review

Neck pain is very common, but most of the causes are unknown, making diagnosis and treatment extremely challenging. Current studies have found that one of the main problems in patients with neck pain is the impairment of cervical proprioception, which subsequently leads to cervical sensorimotor control disturbances. Cervical spine has a very delicate proprioceptive system that plays a crucial role in controlling posture and balance. Cervical proprioceptive impairment in neck pain occurs through a variety of mechanisms. Experimental neck muscle pain induced by injection of hypertonic saline results in inhibition of the activation of painful muscle; chronic neck pain causes structural and functional impairment of cervical muscles; excessive activation of mechanoreceptors in degenerative cervical discs and facet joints produces a large number of erroneous sensory signals. Clinical examinations to assess the link between structural pathology and neck pain have been unsuccessful, opening the way for the development of function-based tests. To date, eight neck sensorimotor control tests have been reported to evaluate patients with chronic neck pain. Although some tests may involve different subsystems (such as oculomotor system and vestibular system), all tests measure sensorimotor control in the neck, and the most commonly used is cervical joint position error (JPE) test. Current studies support the effectiveness of exercises targeting different aspects of sensorimotor function, in particular retraining aimed at improving cervical proprioception and muscle coordination. Based on the available evidence, it is recommended that patients with neck pain should be assessed and managed for cervical proprioceptive impairment and sensorimotor control disturbances.

Multimodal control of neck muscles for vestibular mediated head oscillation damping during walking: a pilot study

Purpose

It is still in question whether head oscillation damping during walking forms a part of the vestibular function. The anatomical pathway from the vestibular system to the neck muscles via the medial vestibulospinal tract (MVST) is well known but there is a lack of knowledge of the exact influence and modulation of each other in daily life activities.

Methods

(I) We fixed a head–neck unit of a human cadaver specimen in a steal frame to determine the required pitch-torque for a horizontal head position. The mean value of the acquired pitch-torque was 0.54 Nm. (II) On a motorized treadmill we acquired kinematic data of the head, the sternum and both feet by wireless 3D IMUs for seven asymptomatic volunteers. Subsequently three randomized task conditions were performed. Condition 1 was walking without any irritation. Condition 2 imitated a sacculus irritation using a standardized cVEMP signal. The third condition used an electric neck muscle-irritation (TENS). The data were analyzed by the simulation environment software OpenSim 4.0.

Results

8 neck muscle pairs were identified. By performing three different conditions we observed some highly significant deviations of the neck muscle peak torques. Analysing Euler angles, we found during walking a LARP and RALP head pendulum, which also was strongly perturbated.

Conclusion

Particularly the pitch-down head oscillation damping is the most challenging one for neck muscles, especially under biomechanical concerns. Mainly via MVST motor activity of neck muscles  might be modulated by vestibular motor signals. Two simultaneous proprioceptor effects might optimize head oscillation damping. One might be a proprioceptive feedback loop to the vestibular nucleus. Another might trigger the cervicocollic reflex (CCR).

Head stabilization during standing in people with persisting symptoms after mild traumatic brain injury

Increased postural sway is often observed in people with mild traumatic brain injury (mTBI), but our understanding of how individuals with mTBI control their head during stance is limited. The purpose of this study was to determine if people with mTBI exhibit increased sway at the head compared with healthy controls. People with persisting symptoms after mTBI (n = 59, 41 women) and control participants (n = 63, 38 women) stood quietly for one minute in four conditions: eyes open on a firm surface (EO-firm), eyes closed on a firm surface (EC-firm), eyes open on a foam pad (EO-foam), and eyes closed on foam (EC-foam). Inertial sensors at the head, sternum, and lumbar region collected tri-axial accelerations. Root-mean-square (RMS) accelerations in anteroposterior (AP) and mediolateral (ML) directions and sway ratios between the head and sternum, head and lumbar, and sternum and lumbar region were compared between groups. Temporal coupling of anti-phase motion between the upper and lower body angular accelerations was assessed with magnitude squared coherence and cross-spectral phase angles. People with mTBI demonstrated greater sway than controls across conditions and directions. During foam-surface conditions, the control group, but not the mTBI group, reduced ML sway at their head and trunk relative to their lumbar by increasing the expression of an anti-phase hip strategy within the frontal plane. These results are consistent with suggestions of inflexible or inappropriate postural control in people with mTBI.

Histologic Observation and Significance of Sympathetic Nerve Fiber Distribution on Human Cervical Ligamentum Flavum

Objective

To study the distribution of sympathetic nerves of the ligamentum flavum (LF), confirm its existence by histological observation and nuclear magnetic resonance spectroscopy, and analyze the relationship between sympathetic nerve fibers and the biomechanical structure of the LF.

Methods

Randomly controlled scientific research selected 15 cases of posterior surgery in the affiliated hospital of Qingdao University from January 2013 to December 2019. The average age was 67.5 ± 14.5 years old, eight males and seven females. The LF specimens (completely separated fresh tissue) of different segments (C_3‐7) were taken during the operation. Two pages of LF specimens on the left and right sides of the same segment are randomly allocated by the pairing method for formalin fixation and cryopreservation in liquid nitrogen. LF specimens extracted from seven other adult cadaver specimens (average age at death of about 56.8 ± 4.0 years, three males and four females) were used as a control group; together with formalin‐ fixed specimens obtained during surgery, 3D slices were given layer by layer. The distribution of sympathetic nerves in different parts of the LF was analyzed by glyoxylic acid‐induced biological monoamine fluorescent technique (SPG) and hematoxylin–eosin (HE) staining. Fifteen liquid nitrogen storage specimens were divided into the back of the LF and the spinal canal through frozen sections, and were analyzed by nuclear magnetic resonance spectroscopy‐hydrogen spectrum (¹H ‐NMR) for neurotransmitters and neurometabolites.

Results

There were type C sympathetic nerve fibers in the LF, which were divided into linear shape (α) and wave shape (β). Experimental group (χ² = 1.705, P > 0.05) and control group (χ² = 0.879, P > 0.05) can detect no difference in fluorescence units. Nerve fiber transmitter metabolites choline (Cho), creator (Cr), γ‐aminobutyric acid (GABA) also indicate that the sympathetic nerve is present in the LF. LF sympathetic nerve fibers were mainly distributed in the proximal spinal canal surface, nerve fibers on the medial belt (area II) were fewer than the lateral belt (area I) (W = 210, P < 0.05). The ¹HNMR spectrum of LF spinal canal PG / Cho (t = 8.721, P < 0.05), GABA (t = 16.01, P < 0.05) value increased, lactic acid (Lac) / Cr (t = 4.213, P < 0.05), Cho / Cr (t = 2.402, P < 0.05) value decreased, indicating that nerve fibers are actively metabolized on the surface of the spinal canal, mainly distributed in tube surface. βtype fibers were more often distributed around microvessels. A small amount of α type fibers went next to the vascular structures, while α type fibers and β type fibers go cross within LF. Two patients with vertebral artery dissection had no recurrence of sympathetic symptoms within a total of 12 follow‐ups 2 years after discharge.

Conclusions

There are many sympathetic nerve fibers distributed on LF, and their distribution may be correlated with histological and mechanical characteristics of LF. It may also be the anatomical basis of cervical vertigo.

Evaluation of cervical spine muscles thickness in patients with cervical vertigo and healthy controls through ultrasonography

[Purpose] Cervical vertigo as a common complaint is associated with some musculoskeletal disorders. However, to date, ultrasonographical parameters of cervical muscles in patients with cervical vertigo have not been investigated. This study was conducted to investigate size of cervical muscles in patients with cervical vertigo compared to healthy controls. [Participants and Methods] Thicknesses of cervical flexor and extensor muscles were evaluated through ultrasonography and results were compared between the patients and healthy controls by Independent Samples t-test or Mann-Whitney U nonparametric test. [Results] Results showed that, thickness of Longus Colli muscle was significantly different between the patients and healthy controls. [Conclusion] According to findings of the study, size of Longus Colli muscle is likely to be associated with etiology of cervical vertigo.

Revisiting "Meniere's Disease" as "Cervicogenic Endolymphatic Hydrops" and Other Vestibular and Cervicogenic Vertigo as "Spectrum of Same Disease": A Novel Concept

Vertigo and dizziness are one of the commonest and least understood symptom. Vestibular vertigo of Meniere's disease and Benign Paroxysmal positional vertigo (BPPV) and cervicogenic dizziness are classified as separate entities. Cervicogenic dizziness is not considered the domain of Otolaryngologists, as it is mainly related to neck proprioceptors. Headache and neck pain, have been found to be associated with both Meniere's disease and BPPV, so is cervicogenic dizziness. The present study was undertaken to study the association between cervical signs and symptoms in patients with Vestibular Vertigo of Meniere's disease, Benign Paroxysmal Positional Vertigo and cervicogenic dizziness. 132 patients complaining of vertigo and diagnosed with Meniere's disease, BPPV or cervicogenic dizziness were examined for symptoms and signs related to neck, shoulder and muscle tightness and asymmetry. Most of the patients of Meniere's Disease (80% for unilateral and 88.23% for bilateral), Benign Paroxysmal Positional Vertigo (75%for right sided BPPV, 66.67% for left sided BPPV) and cervicogenic dizziness (90%) had associated symptoms of neck pain or headache, and were found to be positive for neck tightness and/or asymmetry of shoulder. Headache was more common in patients with Meniere's Disease. Vestibular Dizziness of Meniere's Disease, Benign Paroxysmal Positional Vertigo and Cervicogenic Dizziness may be spectrum of the same disease with underlying myofascial problems. Meniere's Disease of Idiopathic or primary type needs to be revisited as Cervicogenic Hydrops.

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.

A new treatment for cervical vertigo with botulinum toxin

A new and unique treatment for cervical vertigo with botulinum toxin is presented for a woman who sustained neck trauma from being hit by a wave. A diagnosis of cervical vertigo and cervical dystonia was confirmed by history, physical exam, dystonia on EMG exam, and a negative test for benign paroxysmal positional vertigo. She experienced consistent resolution of her vertigo symptoms and pain after each treatment for a total of 5 treatments with botulinum toxin to the upper cervical muscles.This report appears to be the first to demonstrate the missing link between vertigo and cervical dystonia with pain. Chemodenervation was effective in treating cervical vertigo and is likely to have altered the cervical proprioceptive input by relaxing the overactive muscles and/or by decompression of cervical nerves.

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.

Cervical spine radiographs in patients with vertigo and dizziness

OBJECTIVE

The purpose of this study is to investigate the role of cervical radiography in the study of patients with vertigo and dizziness.

PATIENTS

This is a retrospective single-institution case series study of 493 patients suffering from vertigo and dizziness who were referred (from January 2011 to December 2012) to the hospital to study those symptoms.

METHODS

We studied cervical radiographies, CT and MRI of the cervical spine made in the sample and the radiological findings. We analyzed demographic characteristics, presence of psychiatric pathology and emergency assistance due to vertigo in patients who have undergone cervical study.

RESULTS

A total of 57% of patients had cervical radiography made; this was more frequent in women, Spanish people, with psychiatric pathology and who have gone to the emergency department for vertigo (p < 0.05). Degenerative changes were found in 74.1% of the patients with radiography made, more frequently at an older age, osteophytes in 49.5% and abnormal cervical lordosis in 37.1%.

CONCLUSIONS

There are sociodemographic factors that influence in the request for cervical radiographs in patients with vertigo and dizziness. Given the suspicion of cervical vertigo, we do not consider that the findings in the radiographs help in the diagnosis. In our opinion, an excessive use of cervical radiography is made in patients with vertigo and dizziness.

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.

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.

Epidemiology of Cervical Muscle Strains in Collegiate and High School Football Athletes, 2011-2012 Through 2013-2014 Academic Years

CONTEXT

Cervical muscle strains are an often-overlooked injury, with neck- and spine-related research typically focusing on spinal cord and vertebral injuries.

OBJECTIVE

To examine the rates and distributions of cervical muscle strains in collegiate and high school football athletes.

DESIGN

Descriptive epidemiology study.

SETTING

Collegiate and high school football teams.

PATIENTS OR OTHER PARTICIPANTS

The National Collegiate Athletic Association Injury Surveillance Program (NCAA-ISP) collected data from collegiate football athletes. The High School National Athletic Treatment, Injury and Outcomes Network (HS NATION) and High School Reporting Information Online (HS RIO) collected data from high school football athletes. Data from the 2011-2012 through 2013-2014 academic years were used.

MAIN OUTCOME MEASURE(S)

Athletic trainers collected injury and exposure data for football players. Injury counts, injury rates per 10 000 athlete-exposures (AEs), and injury rate ratios with 95% confidence intervals (CIs) were calculated.

RESULTS

The NCAA-ISP reported 49 cervical muscle strains (rate = 0.96/10 000 AEs), of which 28 (57.1%) were TL (time loss; rate = 0.55/10 000 AEs). High School NATION reported 184 cervical muscle strains (rate = 1.66/10 000 AEs), of which 33 (17.9%) were TL injuries (rate = 0.30/10 000 AEs). The HS RIO, which collects only TL injuries, reported 120 TL cervical muscle strains (rate = 0.51/10 000 AEs). The overall injury rate was lower in the NCAA-ISP than in HS NATION (injury rate ratio = 0.58; 95% CI = 0.42, 0.79); when restricted to TL injuries, the overall injury rate was higher in the NCAA-ISP (injury rate ratio = 1.83; 95% CI = 1.11, 3.03). No differences were found when comparing TL injuries in HS RIO and the NCAA-ISP. Cervical muscle-strain rates were higher during competitions than during practices across all 3 surveillance systems for all injuries. Most cervical muscle strains were due to player contact (NCAA-ISP = 85.7%, HS NATION = 78.8%, HS RIO = 85.8%).

CONCLUSIONS

The incidence of cervical muscle strains in football players was low compared with other injuries. Nonetheless, identifying and implementing interventions, particularly those aimed at reducing unsafe player contact, are essential to further decrease the risk of injury and associated adverse outcomes.

Symptoms in cervical vertigo

Objective

To use a unique, 41‐question survey to identify patient features distinguishing cervical vertigo from vestibular causes of vertigo and vestibular migraine.

Methods

In this study, a unique, 41‐question survey was administered to 48 patients diagnosed with cervical vertigo (n = 16), migraine (n = 16), and vestibular vertigo (eg, unilateral vestibular paresis, Meniere's disease) (n = 16) to test the hypothesis that a set of distinct symptoms can characterize cervical vertigo. Responses between the three diagnostic groups were compared to identify questions which differentiated patients based on their symptoms.

Results

Eight questions were successful in differentiating vestibular vertigo from migraine and cervical vertigo. Symptoms endorsed by subjects with cervical vertigo overlapped substantially with subjects with well‐established vestibular disturbances as well as symptoms of subjects with migraine. Twenty‐seven percent of cervical vertigo subjects reported having true vertigo, 50% having headache, and 94% having neck pain.

Conclusion

Lacking knowledge of neck disturbance, the symptoms we elicited in our questionnaire suggest that cervical vertigo subjects may resemble migraine subjects who also have evidence of neck injury. Whether or not subjects with “cervical vertigo” also overlap with other diagnoses defined by a combination of symptoms and exclusion of objective findings such as chronic subjective dizziness and other variants of psychogenic dizziness remain to be established.

Level of Evidence

IV

In Older Patients Treated for Dizziness and Vertigo in Multimodal Rehabilitation Somatic Deficits Prevail While Anxiety Plays a Minor Role Compared to Young and Middle Aged Patients

Objective: Many patients with dizziness and vertigo are of older age. It is still unclear which age-associated factors play a role in the treatment of dizziness and vertigo. Therefore, age-associated characteristics of patients subjected to an interdisciplinary day care approach for chronic vertigo and dizziness were analyzed.

Subjects and Methods: 650 patients with chronic dizziness/vertigo subjected to a multimodal vestibular rehabilitation day care program were analyzed. Information concerning age, gender, medical diagnosis, medical consultations, technical diagnostics performed and therapy achieved before attending the clinic were collected. Furthermore, data were gathered using the Vertigo Severity Scale (VSS), Hospital Anxiety and Depression Scale (HADS), Mobility Inventory (MI), as well as the intensity of and the distress due to vertigo/dizziness using visual analog scales. As a follow-up, the VSS, HADS, MI, and the visual analog scales were collected again 6 months after attending the therapy program. Three age groups were compared to each other (<41, 41–65, and >65 years of age).

Results: One-third of the patients were older than 65 years. This group had typical diagnoses with mainly organic deficits. In contrast to the dominance of mainly multifactorial, organic deficits the older patients reported less medical consultations, fewer technical diagnostics and even fewer treatments than the younger patients. The elderly scored significantly lower in total VSS, in VSS-V (vestibular-balance subscale), in VSS-A (autonomic-anxiety subscale) and in HADS-anxiety. Psychological diagnoses were clearly associated to the younger patients. 424 patients (65.2%) completed the follow-up questionnaire 6 months after attending the therapy week. The older patients revealed improvements of VSS-V and the Avoidance Alone scale of MI as well as decreased distress due to vertigo/dizziness.

Conclusion: In the older patients, who took part in our vestibular rehabilitation program, mainly somatic deficits prevail while anxiety plays a minor role compared to young and middle aged patients. Older patients profited from vestibular rehabilitation especially in mobility and vestibular-balance. Therefore, vestibular rehabilitation programs for the elderly with a focus on physio- and occupational therapeutic interventions and less cognitive behavioral therapy may be reasonable.

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.

Measuring pressure pain threshold in the cervical region of dizzy patients-The reliability of a pressure algometer

OBJECTIVES

A tool for measuring neck pain in patients with dizziness is needed to further investigate the relationship between the two symptoms. The objective of this study was to examine the reliability and validity of a hand-held pressure algometer in measuring pressure pain threshold (PPT) in different cervical regions of dizzy patients.

METHODS

PPT was measured at two bilateral standardized sites of the neck by a trained physiotherapist in 50 patients with dizziness. Intraclass correlation coefficients (ICC) were calculated for intrarater and test-retest reliability. Concurrent validity was assessed by measuring the association between PPT and the American College of Rheumatology (ACR) tender points at each site and with the numeric pain rating scale (NPRS).

RESULTS

Almost perfect intrarater (ICC = 0.815-0.940) and within-session test-retest (ICC = 0.854-0.906) reliability was found between the measures. On each site, a low PPT predicted a positive ACR tender point at each site (OR = 0.864-0.922). Last, we found a statistical inverse relationship between the PPT and the NPRS (R = -0.52 to -0.66).

CONCLUSION

The study shows that a pressure algometer is a reliable tool for measuring PPT in the neck of dizzy patients. Further, the PPT correlates significantly with other subjective measures of pain indicating that it may be a useful tool for further research.

Cervical Intervertebral Disc Degeneration Contributes to Dizziness: A Clinical and Immunohistochemical Study

OBJECTIVES

Dizziness often happens in patients with chronic neck pain with only cervical disc degeneration but without cervical radiculopathy or myelopathy. We prospectively selected a series of patients who showed cervical disc degeneration with concomitant chronic neck pain and intractable dizziness who did not respond to conservative treatment to test a new diagnostic method for this dizziness, to analyze the results of anterior cervical discectomy and fusion (ACDF) surgery based on the test, and to explore its pathogenesis.

METHODS

Seventy-seven patients who had a transient neck pain and dizziness relief after injection of bupivacaine into a suspected disc were included in the study. In total, 52 underwent ACDF as surgery group, and 25 refused surgery and accepted conservative treatments as conservative group from June, 2015 to October, 2016 with subsequent follow-up to 1 year. The outcomes were visual analogue scale for neck pain, Neck Disability Index, and intensity and frequency of dizziness. During ACDF, the 72 specimens of degenerative cervical discs were collected to determine the innervation in degenerative cervical discs immunohistochemically.

RESULTS

After surgery, the patients experienced a significant reduction in neck pain and dizziness. Symptomatic relief in surgery group was obviously better than conservative group at each time point of follow-up (P = 0.001). Ruffini corpuscles and substance P-positive free nerve fibers were obviously increased in the number and deeply ingrown into the inner degenerative cervical discs.

CONCLUSIONS

Current clinical and immunohistochemical studies strongly suggest that chronic neck pain and intractable dizziness in this series of patients stem from the degenerative cervical discs.

Importance of cervicogenic general dizziness

A 15-month retrospective study of 1,000 outpatients was conducted to determine the exact cause of general dizziness. The most common diagnosis in all analyzed cases was cervicogenic general dizziness (89%). The majority of the patients who underwent magnetic resonance imaging of the cervical spine had narrow spinal canals. Measuring the anteroposterior diameter of the spinal canal in each case was critical to obtain an accurate diagnosis in line with the diagnostic criteria used. General dizziness may develop because of inappropriate neck posture over long periods of time in individuals with some form of underlying cervical disease. The causes of general dizziness were different between male and female patients and between patients of different age groups. Triggers leading to general dizziness included engaging in farming, gardening, or weeding activities for long periods of time, particularly in elderly women. Selection of the appropriate muscle relaxant type and dosage is important in the treatment of patients with cervicogenic general dizziness who also experience a stiff neck and shoulders. Following treatment, 90% of patients no longer experienced general dizziness or exhibited clear improvements in their symptoms within 1 week. The results of this study emphasize the importance of cervicogenic general dizziness, which is due to cervical vertebral lesions and is exacerbated by excessive stress on the cervical spine.

Atypical symptoms in patients with cervical spondylosis: Comparison of the treatment effect of different surgical approaches

To compare the effectiveness of total disk replacement (TDR), anterior cervical discectomy and fusion (ACDF), and laminoplasty on atypical symptoms of cervical spondylosis.Patients with confirmed diagnosis of cervical spondylosis and reported atypical symptoms such as blurred vision, headache, nausea, palpitation, tinnitus, vertigo, hypomnesia, and abdominal discomfort were retrospectively included in the present study. They were treated with TDR, ACDF, or laminoplasty depending on the etiology and patient preference. Severity of the atypical symptoms before the surgery and at the end of 2-year follow-up was recorded and the degree of severity alleviation was compared between different surgical approaches.A total number of 336 patients who were treated in our institute from February 2002 to March 2011 were included in the final analysis. Atypical symptoms were significantly alleviated in most patients after surgical intervention. No significant differences were found regarding the change of severity of those symptoms among patients in different surgery groups.TDR, ACDF, and laminoplasty can equally alleviate the severity of atypical symptoms in patients with cervical spondylosis. This indicates that the neural network in the posterior longitudinal ligament may not be the cause of atypical symptoms in patients with cervical spondylosis.

The effectiveness of anterior cervical decompression and fusion for the relief of dizziness in patients with cervical spondylosis: a multicentre prospective cohort study

AIMS

Cervical spondylosis is often accompanied by dizziness. It has recently been shown that the ingrowth of Ruffini corpuscles into diseased cervical discs may be related to cervicogenic dizziness. In order to evaluate whether cervicogenic dizziness stems from the diseased cervical disc, we performed a prospective cohort study to assess the effectiveness of anterior cervical discectomy and fusion on the relief of dizziness.

PATIENTS AND METHODS

Of 145 patients with cervical spondylosis and dizziness, 116 underwent anterior cervical decompression and fusion and 29 underwent conservative treatment. All were followed up for one year. The primary outcomes were measures of the intensity and frequency of dizziness. Secondary outcomes were changes in the modified Japanese Orthopaedic Association (mJOA) score and a visual analogue scale score for neck pain.

RESULTS

There were significantly lower scores for the intensity and frequency of dizziness in the surgical group compared with the conservative group at different time points during the one-year follow-up period (p = 0.001). There was a significant improvement in mJOA scores in the surgical group.

CONCLUSION

This study indicates that anterior cervical surgery can relieve dizziness in patients with cervical spondylosis and that dizziness is an accompanying manifestation of cervical spondylosis. Cite this article: Bone Joint J 2018;100-B:81-7.

Vertigo and dizziness in adolescents: Risk factors and their population attributable risk

OBJECTIVES

To assess potential risk factors for vertigo and dizziness in adolescents and to evaluate their variability by different vertigo types. The role of possible risk factors for vertigo and dizziness in adolescents and their population relevance needs to be addressed in order to design preventive strategies.

STUDY DESIGN

The study population consisted of 1482 school-children between the age of 12 and 19 years, who were instructed to fill out a questionnaire on different vertigo types and related potential risk factors. The questionnaire specifically asked for any vertigo, spinning vertigo, swaying vertigo, orthostatic dizziness, and unspecified dizziness. Further a wide range of potential risk factors were addressed including gender, stress, muscular pain in the neck and shoulder region, sleep duration, migraine, coffee and alcohol consumption, physical activity and smoking.

RESULTS

Gender, stress, muscular pain in the neck and shoulder region, sleep duration and migraine were identified as independent risk factors following mutual adjustment: The relative risk was 1.17 [1.10-1.25] for female sex, 1.07 [1.02-1.13] for stress, 1.24 [1.17-1.32] for muscular pain, and 1.09 [1.03-1.14] for migraine. The population attributable risk explained by these risk factors was 26%, with muscular pain, stress, and migraine accounting for 11%, 4%, and 3% respectively.

CONCLUSION

Several established risk factors in adults were also identified in adolescents. Risk factors amenable to prevention accounted for 17% of the total population risk. Therefore, interventions targeting these risk factors may be warranted.

Cervical Vertigo: Historical Reviews and Advances

Vertigo is one of the most common presentations in adult patients. Among the various causes of vertigo, so-called cervical vertigo is still a controversial entity. Cervical vertigo was first thought to be due to abnormal input from cervical sympathetic nerves based on the work of Barré and Liéou in 1928. Later studies found that cerebral blood flow is not influenced by sympathetic stimulation. Ryan and Cope in 1955 proposed that abnormal sensory information from the damaged joint receptors of upper cervical regions may be related to pathologies of vertigo of cervical origin. Further studies found that cervical vertigo seems to originate from diseased cervical intervertebral discs. Recent research found that the ingrowth of a large number of Ruffini corpuscles into diseased cervical discs may be related to vertigo of cervical origin. Abnormal neck proprioceptive input integrated from the signals of Ruffini corpuscles in diseased cervical discs and muscle spindles in tense neck muscles secondary to neck pain is transmitted to the central nervous system and leads to a sensory mismatch with vestibular and other sensory information, resulting in a subjective feeling of vertigo and unsteadiness. Further studies are needed to illustrate the complex pathophysiologic mechanisms of cervical vertigo and to better understand and manage this perplexing entity.

Disturbed cervical proprioception affects perception of spatial orientation while in motion

The proprioceptive, visual and vestibular sensory systems interact to maintain dynamic stability during movement. The relative importance and interplay between these sensory systems is still not fully understood. Increased knowledge about spatial perception and postural orientation would provide better understanding of balance disorders, and their rehabilitation. Displacement of the body in space was recorded in 16 healthy subjects performing a sequence of stepping-in-place tests without any visual or auditory cues. Spatial displacement and orientation in space were determined by calculating two parameters, “Moved distance (sagittal + lateral displacement)” and “Rotation”. During the stepping-in-place tests vibration were applied in a randomized order on four different cervical muscles, and the effects were compared between muscles and to a non-vibration baseline condition. During the tests a forward displacement (“Moved distance”) was found to be the normal behavior, with various degrees of longitudinal rotation (“Rotation”). The moved distance was significantly larger when the vibration was applied on the dorsal muscles (916 mm) relative to on ventral muscles (715 mm) (p = 0.003) and the rate of displacement was significantly larger for dorsal muscles (36.5 mm/s) relative to ventral (28.7 mm/s) vs (p = 0.002). When vibration was applied on the left-sided muscles, 16° rotation to the right was induced (p = 0.005), whereas no significant rotation direction was induced with right-sided vibration (3°). The rate of rotation was significantly larger for vibration applied on ventral muscles (0.44°/s) relative to on dorsal (0.33°/s) (p = 0.019). The results highlight the influence of cervical proprioception on the internal spatial orientation, and subsequent for postural control.