Cervical vertigo--reality or fiction?

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.

Video-oculographic measures of eye movement control in the smooth pursuit neck torsion test can classify idiopathic neck pain patients from healthy individuals: A datamining based diagnostic accuracy study

BACKGROUND

Idiopathic neck pain patients frequently experience oculomotor disfunctions with deficits in eye movement control between neutral and neck torsion position (SPNT test) being commonly investigated in clinical and research settings.

OBJECTIVES

The aim of the study was to determine accuracy of SPNT test in classifying idiopathic neck pain patients.

DESIGN

a datamining based diagnostic accuracy study.

METHODS

The study was conducted on a referred sample of 38 chronic neck pain patients from orthopaedic outpatient clinic and 40 healthy controls. Video-oculography was used to study gain and SPNT_diff during SPNT test under three target movement velocities and amplitudes and two different angles of neck torsion. A Naïve Bayesian predictive model was used to classify neck pain patients based on gain or SPNT_diff.

RESULTS

Gain during two target movement profiles at velocities of 30°s^-1 and amplitudes of 30° and 40° under 45° of neck torsion presented with highest area under the curve (0.837), specificity (92%), sensitivity (94%), highest true positive and lowest false negative predicted value. Highest area under the curve (0.760), specificity (50%), sensitivity (71%), highest true positive and lowest false negative values were observed for SPNT_diff at velocities of 30°s^-1 and amplitude of 30° applying 45° of neck torsion.

CONCLUSION

SPNT test provides useful diagnostic tool for classifying neck pain patients when using single or combination of two target movement profiles. Neck torsion of 45° as opposed to 30° should be used during SPNT test when investigating patients with neck pain disorders.

Relationship between Cervicocephalic Kinesthetic Sensibility Measured during Dynamic Unpredictable Head Movements and Eye Movement Control or Postural Balance in Neck Pain Patients

Cervical afferent input is believed to affect postural balance and oculomotor control in neck pain patients, but its relationship to cervicocephalic kinesthesia, describing movement sense, has not yet been studied. The aim of this study was to analyze the relationship of two aspects of cervicocephalic kinesthesia to postural balance and oculomotor control in neck torsion positions. Forty-three idiopathic neck pain patients referred from orthopedic outpatient clinics and forty-two asymptomatic controls were enrolled in the study. A force plate was used to measure center-of-pressure movements during parallel stances under neutral and neck torsion maneuvers. Video-oculography was used to assess eye movements during smooth pursuit neck torsion test (SPNTT), while kinesthetic awareness was measured using the Butterfly test and head-to-neutral relocation test. Multiple regression was used to describe relationships between tests. Body sway in the anterior-posterior direction was related to Butterfly parameters but less to the head-to-neutral test. A medium relationship between Butterfly parameters and gain during SPNTT, with less SPNT-difference, was observed, but not for the head-to-neutral test. It can be concluded that specific aspect of neck kinesthetic functions (i.e., movement sense) importantly contributes towards oculomotor and balance control, which is more evident under neck torsion positions in neck pain patients, but is less pronounced in asymptomatic individuals.

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.

[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.

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.

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.

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.

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

Hypnotic Intervention for Unexplained Dizziness in Patients with Advanced Cancer: A Preliminary Retrospective Observation Study

Context:

Patients with advanced cancer rarely complain of unexplained dizziness after excluding identifiable causes. Some patients become anxious because they attribute the dizziness to the progression of their cancer. We hypothesize that unexplained dizziness is associated with neck muscle hypertonicity, a noncancer-related secondary effect. However, most cases are associated with neck muscle hypertonicity, a noncancer-related secondary effect.

Aims:

We evaluated the usefulness of hypnotic intervention that made patients aware of the relation between dizziness and neck muscle hypertonicity through the experience of muscle relaxation and recognition of muscle tension.

Settings and Design:

Advanced cancer patients requiring palliative care with unexplained dizziness who received the intervention to induce neck muscle relaxation were retrospectively compared with patients who did not.

Subjects and Methods:

The severity of dizziness that was evaluated using a numeric rating scale and the intervention efficacy rate were compared between the hypnotic and nonhypnotic groups as the primary endpoints, 7 days after the start of the intervention. Secondary endpoints included the effect size based on dizziness handicap inventory (DHI) scores before and after the intervention, and changes in patients’ awareness of the cause of dizziness.

Results:

The hypnotic intervention had a significantly greater efficacy rate (0.67, 95% confidence interval: 0.46–0.88) than the nonhypnotic intervention (0.26, 95% confidence interval: 0.08–0.44). DHI scores, especially on the emotional subscale, showed significant improvement after the intervention, and 71% of the patients were aware that neck muscle hypertonicity was the cause of dizziness.

Conclusions:

The rapid improvement in dizziness in the hypnotic group was considered to result from a change in patients’ awareness of self-manageable neck muscle hypertonicity as the cause of dizziness.

Vestibular dysfunction and concussion

The assessment and treatment of sport-related concussion (SRC) often requires a multifaceted approach. Vestibular dysfunction represents an important profile of symptoms and pathology following SRC, with high prevalence and association with prolonged recovery. Signs and symptoms of vestibular dysfunction may include dizziness, vertigo, disequilibrium, nausea, and visual impairment. Identifying the central and peripheral vestibular mechanisms responsible for pathology can aid in management of SRC. The most common vestibular disturbances after SRC include benign paroxysmal positional vertigo, vestibulo-ocular reflex impairment, visual motion sensitivity, and balance impairment. A variety of evidence-based screening and assessment tools can help to identify the various types of vestibular pathology in SRC. When vestibular dysfunction is identified, there is emerging support for applying targeted vestibular rehabilitation to manage this condition.

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 from the perspective of an otorhinolaryngologist]

At present, the skeptical attitude toward the term 'cervical vertigo' (CV) predominates in the ENT-community. Such point of view is attributable to the absence of specific CV symptoms and well-defined diagnostic criteria. The present literature review was designed to consider the results of the clinical observations and experimental investigations obtained during the past 150 years that give evidence of the possibility to regard cervical vertigo as a separate nosological entity. The characteristic signs of this condition are analyzed and systematized. Four CV variants are currently distinguished. The principles of diagnostics and treatment of cervical vertigo are discussed and general concept of CV is formulated.

Mastoid vibration affects dynamic postural control during gait in healthy older adults

Vestibular disorders are difficult to diagnose early due to the lack of a systematic assessment. Our previous work has developed a reliable experimental design and the result shows promising results that vestibular sensory input while walking could be affected through mastoid vibration (MV) and changes are in the direction of motion. In the present paper, we wanted to extend this work to older adults and investigate how manipulating sensory input through mastoid vibration (MV) could affect dynamic postural control during walking. Three levels of MV (none, unilateral, and bilateral) applied via vibrating elements placed on the mastoid processes were combined with the Locomotor Sensory Organization Test (LSOT) paradigm to challenge the visual and somatosensory systems. We hypothesized that the MV would affect sway variability during walking in older adults. Our results revealed that MV significantly not only increased the amount of sway variability but also decreased the temporal structure of sway variability only in anterior-posterior direction. Importantly, the bilateral MV stimulation generally produced larger effects than the unilateral. This is an important finding that confirmed our experimental design and the results produced could guide a more reliable screening of vestibular system deterioration.

Efficacy of Carbon Microcoils in Relieving Cervicogenic Dizziness

Introduction Cervical pain contributes to postural deviations and imbalance. Nanotechnology may be used for the treatment of neck pain by fixing to the skin small rounds silicone patches containing double spiral carbon nanotubes arranged in the form of a coil (Helical), which would then relieve dizziness caused by muscular contraction.

Objective The objective of this study is to Evaluate pain and dizziness scores before and after Helical patches effect on cervicogenic dizziness treatment.

Methods The selected patients should have neck pain arising from muscle contraction with loss of balance or instability lasting more than 90 days and normal electrooculography. Treatment consisted of placing 10 Helical patches distributed as follows: two in the upper cervical area, two in the lower cervical area (near the 5^th and 6^th vertebrae), two in the upper trapezius muscle area (between neck and shoulder), and four in the tender point area (as reported by the patient). Using a Visual Analogue Scale (VAS), we matched pain and dizziness scores from Day 1 to those from Day 15 and Day 30 using Mann-Whitney test.

Results There was a significant difference between pain score reported on Day 1 and Day 15 (Z = 2.43, U = 5, p = 0.01). We also found significant differences between dizziness scores reported on days 1 and 15 (Z = 2.62, U = 3.5, p = 0.01) and days 1 and 30 (Z = 2.36, U = 5.5, p = 0.01).

Conclusion The Helical patches seem to be an effective treatment for cervicogenic dizziness.

Mastoid Vibration Affects Dynamic Postural Control During Gait

Our objective was to investigate how manipulating sensory input through mastoid vibration (MV) could affect dynamic postural control during walking, with and without simultaneous manipulation of the visual and the somatosensory systems. We used three levels of MV (none, unilateral, and bilateral) via vibrating elements placed on the mastoid processes. We combined this with the six conditions of the Locomotor Sensory Organization Test (LSOT) paradigm to challenge the visual and somatosensory systems. We hypothesized that MV would affect both amount and temporal structure measures of sway variability during walking and that, in combination with manipulations of the visual and the somatosensory inputs, MV would augment the effects previously observed. The results confirmed that MV produced a significant increase in the amount of sway variability in both anterior-posterior and medial-lateral directions. Significant changes in the temporal structure of sway variability were only observed in the anterior-posterior direction. Bilateral MV produced larger effects than unilateral stimulation. We concluded that sensory input while walking could be affected using MV. Combining MV with manipulations of visual and somatosensory input could allow us to better understand the contributions of the sensory systems during locomotion.

The effect of neurac training in patients with chronic neck pain

[Purpose] This study aimed to investigate the effects of neurac training on pain, function, balance, fatigability, and quality of life. [Subjects and Methods] Subjects with chronic neck pain who were treated in S hospital were included in this study; they were randomly allocated into two groups, i.e., the experimental group (n = 10) and the control group (n = 10). Both groups received traditional physical therapy for 3 sessions for 30 min per week for 4 weeks. The experimental group practiced additional neurac training for 30 min/day, for 3 days per week for 4 weeks. All subjects were evaluated using the visual analogue scale (VAS), the neck disability index (NDI), the biorescue (balance), the questionnaire for fatigue symptoms (fatigue), and the medical outcome 36-item short form health survey (SF-36) pre- and post-intervention. [Results] The experimental group effectively improved their pain, function, balance, fatigability, and quality of life. [Conclusion] Neurac training is thus considered an effective training program that enhances body functionality by improving pain, function, balance ability, fatigability, and quality of life in patients with chronic neck pain.

Experimentally induced deep cervical muscle pain distorts head on trunk orientation

PURPOSE

We wanted to explore the specific proprioceptive effect of cervical pain on sensorimotor control. Sensorimotor control comprises proprioceptive feedback, central integration and subsequent muscular response. Pain might be one cause of previously reported disturbances in joint kinematics, head on trunk orientation and postural control. However, the causal relationship between the impact of cervical pain on proprioception and thus on sensorimotor control has to be established.

METHODS

Eleven healthy subjects were examined in their ability to reproduce two different head on trunk targets, neutral head position (NHP) and 30° target position, with a 3D motion analyser before, directly after and 15 min after experimentally induced neck pain. Pain was induced by hypertonic saline infusion at C2/3 level in the splenius capitis muscle on one side (referred to as "injected side").

RESULTS

All subjects experienced temporary pain and the head repositioning error increased significantly during head repositioning to the 30° target to the injected side (p = 0.011). A post hoc analysis showed that pain interfered with proprioception to the injected side during acute pain (p < 0.001), but also when the pain had waned (p = 0.002). Accuracy decreased immediately after pain induction for the 30° target position to the side where pain was induced (3.3 → 5.3°, p = 0.033), but not to the contralateral side (4.9 → 4.1°, p = 0.657). There was no significant impact of pain on accuracy for NHP. A sensory mismatch appeared in some subjects, who experienced dizziness.

CONCLUSIONS

Acute cervical pain distorts sensorimotor control with side-specific changes, but also has more complex effects that appear when pain has waned.

Efficacy of manual therapy treatments for people with cervicogenic dizziness and pain: protocol of a randomised controlled trial

BACKGROUND

Cervicogenic dizziness is a disabling condition characterised by postural unsteadiness that is aggravated by cervical spine movements and associated with a painful and/or stiff neck. Two manual therapy treatments (Mulligan's Sustained Natural Apophyseal Glides (SNAGs) and Maitland's passive joint mobilisations) are used by physiotherapists to treat this condition but there is little evidence from randomised controlled trials to support their use. The aim of this study is to conduct a randomised controlled trial to compare these two forms of manual therapy (Mulligan glides and Maitland mobilisations) to each other and to a placebo in reducing symptoms of cervicogenic dizziness in the longer term and to conduct an economic evaluation of the interventions.

METHODS

Participants with symptoms of dizziness described as imbalance, together with a painful and/or stiff neck will be recruited via media releases, advertisements and mail-outs to medical practitioners in the Hunter region of NSW, Australia. Potential participants will be screened by a physiotherapist and a neurologist to rule out other causes of their dizziness. Once diagnosed with cervciogenic dizziness, 90 participants will be randomly allocated to one of three groups: Maitland mobilisations plus range-of-motion exercises, Mulligan SNAGs plus self-SNAG exercises or placebo. Participants will receive two to six treatments over six weeks. The trial will have unblinded treatment but blinded outcome assessments. Assessments will occur at baseline, post-treatment, six weeks, 12 weeks, six months and 12 months post treatment. The primary outcome will be intensity of dizziness. Other outcome measures will be frequency of dizziness, disability, intensity of cervical pain, cervical range of motion, balance, head repositioning, adverse effects and treatment satisfaction. Economic outcomes will also be collected.

DISCUSSION

This paper describes the methods for a randomised controlled trial to evaluate the effectiveness of two manual therapy techniques in the treatment of people with cervicogenic dizziness for which there is limited established evidence-based treatment.

TRIAL REGISTRATION

ACTRN12611000073909.

Impaired postural control in patients affected by tension-type headache

Sixteen subjects, affected by chronic tension-type headache (TTH) accordingly to the International Headache Society Classification (1988) criteria, in presence of tenderness in pericranial muscles,with a mean age of 37+/-11.8 years, and ten healthy volunteer subjects, age and sex matched, were submitted to postural analysis by Static Posturography (S.Ve.P. Amplaid). Aim of the study was to evaluate whether patients with TTH have disturbed postural control, as compared to normal subjects. Postural analysis considered all posturographic variables but focused on spectral frequency analysis of body sway. In both open (OE) and closed eyes (CE) condition, spectral frequency analysis showed a significantly increased body sway at low (OE= p < or = 0.01; CE= p < or = 0.01) and middle (OE= p < or = 0.01; CE= p < or = 0.01) frequencies on the antero-posterior (y) plane and at low frequencies (OE= p < or = 0.05; CE= p < or = 0.05) on the lateral (x) plane. Statistical analysis was performed using the Student's t test for unpaired data, p value 0.05 defined significant. The proprioceptive input seems to be predominant at middle and high frequencies in maintaining posture, our results seem then to suggest a proprioceptive disturbance in TTH patients. The disturbance is likely related to chronic pericranial muscle contraction and tenderness. Posturography and spectral analysis may help not only in the diagnosis of a postural disturbance but even more in the follow-up of TTH patients, during and after a medical and/or a rehabilitative treatment.

A review of the burden of vertigo

AIM AND OBJECTIVES

To provide an overview of vertigo and its management and identify its impact on individuals to offer strategies for managing the condition.

BACKGROUND

Dizziness and vertigo are symptoms common to many pathologies/dysfunctions ranging from the benign to the potentially serious; many are poorly understood. Although rarely life-threatening, vertigo is debilitating and significantly affects quality of life; it may be as disabling as paralysis or loss of a limb. Although 40-80% of cases remain unexplained, referral for specific investigation is rare.

DESIGN

A narrative literature review including descriptive, theoretical and empirical material reliant on the keywords 'dizziness' and 'vertigo' and the phrase 'vestibular disorders'. This provided diverse information that was used to address the research questions.

RESULTS

Vertigo is a widespread and potentially distressing symptom that may arise at any age and be acute or chronic. For most, it resolves spontaneously; for others, dizziness persists, causing significant distress. Its management is challenging, especially when the underlying cause is unclear. Pharmacological interventions, physiotherapy, psychotherapy or, rarely, surgery can be used in its management. Few nursing studies are available, suggesting that nursing knowledge may be limited.

RELEVANCE TO CLINICAL PRACTICE

Although nurses may frequently encounter patients with vertigo, there are few relevant nursing studies in this area; few consider appropriate nursing interventions or approaches to patient care. The information provided reveals that understanding the full impact of the condition and identification of patients' needs are essential to effective care. Some strategies to help affected patients are outlined.

CONCLUSIONS

Vertigo, a widespread, often intractable condition, affects significant numbers of people; diagnosis and management can be challenging. Treatment, care and support must be selected on an individual basis taking individuals into account. The primary goals are to maintain physical status, psychosocial interaction and quality of life.

Effects of vision and tactile stimulation of the neck on postural control during unperturbed stance and cervical joint position sense in young asymptomatic adults

STUDY DESIGN

Before and after intervention trials.

OBJECTIVE

To evaluate the effects of visual input and tactile stimulation of the neck on postural control during unperturbed stance and cervical joint position sense.

SUMMARY OF BACKGROUND DATA

Although beneficial effects on lower-limb joints proprioception have been reported when vision was available and when tactile stimulation was applied around lower-limb joints, there has hitherto been no study investigating whether and how vision and tactile stimulation applied to the neck could modify postural control during unperturbed stance and joint position sense.

METHODS

The effects of visual input and tactile stimulation of the neck on postural control during unperturbed stance (Experiments 1 and 2) and cervical joint position sense (Experiments 3 and 4) were assessed in four separate experiments. During these experiments, two experimental tasks (a postural task during unperturbed stance and the CRT to NHP) were executed without (No vision) and with the availability of the vision (Vision) and without (No tactile stimulation condition) and with the application of strips of adhesive bandage to the skin over and around the neck (Tactile stimulation condition). Twelve different subjects participated in the four experiments.

RESULTS

For experiments 1 and 2, decreased centre of foot pressure displacements were observed in the Vision relative to the No vision and in the Tactile stimulation relative to the No tactile stimulation condition. For experiments 3 and 4, more accurate and more consistent repositioning performances were observed in the Vision relative to the No vision and in the Tactile stimulation relative to the No tactile stimulation condition, as indicated by decreased absolute and variable errors, respectively.

CONCLUSION

Altogether, our results suggest that subjects were able to take advantage of vision and increased neck cutaneous information provided by the by strips of adhesive bandage applied to the neck to improve postural control during unperturbed stance and cervical joint position sense.

[Results evaluation in cervical vertigo kinesitherapy--preliminary report]

INTRODUCTION

The work aimed at analyzing results of kinesitherapeutic procedures in patients with cervical vertigo as well as evaluating a mobility range of the cervical spine.

MATERIAL AND METHODS

The study was conducted on 23 people, including 17 women and 6 men suffering from cervical vertigo, at the age of 23-73 (the average age of 49.5). All the patients had an individually selected cycle of kinesitherapeutic exercises through the period of 2 months. The objective efficiency evaluation of the applied therapy was made on the grounds of the videonystagmographic examination (VNG). Additionally, the range of active mobility of the cervical spine was analyzed and the evaluation of vertigo according to Silvoniemi's criteria was performed.

STUDY RESULTS

After a 2-month therapy 4 patients (17.4%) out of the examined material showed a total lack of vertigo, 15 patients (65.2%) demonstrated a meaningful decrease in the vertigo intensity, also in the frequency of their occurrence in 14 cases (60.8%). Only 3 patients did not show any decrease in vertigo whereas in 1 patient a slight increase in the intensity was indicated. On the basis of a subjective evaluation of the vertigo increase according to the 5-stage Silvoniemi's scale it was proved that a mean point assessment claimed by the patients at the beginning of the therapy amounts to 3.0 points whereas after the therapy it was as follows: 1.43 pt after 2 weeks, 1.17 pt after 1 month and 1.13 pt after 2 months of kinesitherapy.

CONCLUSIONS

It is extremely difficult to fully eliminate the symptoms of cervical vertigo (in the studied material in 4 cases--17.3%) because the causes of their occurrence, which are connected with excessive tension and degeneration in the cervical spine, cannot usually be eradicated. Additionally, as a diagnostic means, the videonystagmographic examination (VNG) accompanied by the positioning tests and the cervical rotation test facilitates precise and objective monitoring of the progress in treatment and rehabilitation of vertigo.

Degradation of cervical joint position sense following muscular fatigue in humans

STUDY DESIGN

Before and after intervention trials.

OBJECTIVE

To investigate the effect of cervical muscular fatigue on joint position sense.

SUMMARY OF BACKGROUND DATA

Although fatigue-related degradation of proprioceptive acuity at lower and upper limbs is well documented, to date no study has investigated whether muscular fatigue induced at the neck could modify joint position sense.

METHODS

A total of 9 young healthy adults were asked to perform the cervicocephalic relocation test to the neutral head position, that is, to relocate the head on the trunk, as accurately as possible, after full active cervical rotation to the left and right sides. This experimental task was executed in 2 conditions of No fatigue and Fatigue of the scapula elevator muscles. Absolute and variable errors were used to assess the cervical joint repositioning accuracy and consistency, respectively.

RESULTS

Less accurate and less consistent repositioning performances were observed in Fatigue relative to No fatigue condition, as indicated by increased absolute and variable errors, respectively.

CONCLUSION

Results of the present experiment evidence that cervical joint position sense, assessed through the cervicocephalic relocation test to the neutral head position, is degraded by muscular fatigue.

Sound evoked triceps myogenic potentials

OBJECTIVE

To determine if a sound evoked myogenic potential could be obtained from the triceps with the recording and stimulus parameters routinely used to obtain a vestibular evoked myogenic potential (VEMP) from the sternocleidomastoid.

STUDY DESIGN

Prospective study of myogenic potentials recorded from the triceps in healthy subjects. We used a monaural acoustic stimulus and measured the unrectified myogenic potential using surface electromyography electrodes, using response-triggered averaging, on the triceps of 18 subjects.

SETTING

University-affiliated otoneurology clinic.

PATIENTS

Eighteen healthy adult volunteers (11 women and 7 men), age ranging between 27 and 36 years.

MAIN OUTCOME MEASURES

Latencies and amplitudes of the first two waves of the evoked response.

RESULTS

: The P1 latency was 36.83 +/- 8.42 ms (range, 26.34-57.99 ms; 95% confidence interval [CI], 33.53-40.14 ms), the N1 latency was 43.74 +/- 8.80 ms (range, 34.67-66.32 ms; 95% CI, 40.29-47.19 ms), the P1-N1 interlatency was 6.90 +/- 1.23 ms (range, 5.21-9.79 ms; 95% CI, 6.42-7.39 ms), and the P1-N1 interamplitude was 93.23 +/- 51.25 microV (range, 16.33-206.62 microV; 95% CI, 73.14-113.32 V).

CONCLUSION

A monaural sound stimulus elicits a robust and reproducible surface myogenic potential in triceps muscles.

Cervicogenic dizziness – musculoskeletal findings before and after treatment and long-term outcome

PURPOSE

To explore musculoskeletal findings in patients with cervicogenic dizziness and how these findings relate to pain and dizziness. To study treatment effects and long-term symptom progress.

METHOD

Twenty-two patients (20 women, 2 men; mean age 37 years) with suspected cervicogenic dizziness underwent a structured physical examination before and after physiotherapy guided by the musculoskeletal findings. Questionnaires were sent to the patients six months and two years after treatment.

RESULTS

Dorsal neck muscle tenderness and tightness was found in a majority of the patients. Zygapophyseal joint tenderness was found at all cervical levels. Cervical range of motion was equal to or larger than expected age and gender matched values. The cervico-thoracic region was often hypomobile. Most patients had postural imbalance. Dynamic stabilization capacity was reduced. Suboccipital muscles tightness correlated with posture imbalance and poor neck stability. The treatment resulted in reduced tenderness in levator scapula, high and middle paraspinal and temporalis muscles and zygapophyseal joints at C4-C7 and increased cervico-thoracic mobility. Reduction of middle paraspinal muscle tenderness correlated with neck pain relief. Postural alignment improved, as did dynamic stabilization in trunk, neck and shoulders. After 6 months, 13 of the 17 patients had still no or less neck pain and 14 had no or less dizziness. After 2 years, 7 patients had no or less neck pain and 11 no or less dizziness.

CONCLUSION

Patients with suspected cervicogenic dizziness have some musculoskeletal findings in common. Treatment based on these findings reduces neck pain as well as dizziness long-term but some patients might need a maintenance strategy.

Reduced performance in balance, walking and turning tasks is associated with increased neck tone in Parkinson's disease

Rigidity or hypertonicity is a cardinal symptom of Parkinson's disease (PD). We hypothesized that hypertonicity of the body axis affects functional performance of tasks involving balance, walking and turning. The magnitude of axial postural tone in the neck, trunk and hip segments of 15 subjects with PD (both ON and OFF levodopa) and 15 control subjects was quantified during unsupported standing in an axial twisting device in our laboratory as resistance to torsional rotation. Subjects also performed six functional tests (walking in a figure of eight [Figure of Eight], Timed Up and Go, Berg Balance Scale, supine rolling task [rollover], Functional Reach, and standing 360-deg turn-in-place) in the ON and OFF state. Results showed that PD subjects had increased tone throughout the axis compared to control subjects (p=0.008) and that this increase was most prominent in the neck. In PD subjects, axial tone was related to functional performance, but most strongly for tone at the neck and accounted for an especially large portion of the variability in the performance of the Figure of Eight test (r(OFF)=0.68 and r(ON)=0.74, p<0.05) and the Rollover test (r(OFF)=0.67 and r(ON)=0.55, p<0.05). Our results suggest that neck tone plays a significant role in functional mobility and that abnormally high postural tone may be an important contributor to balance and mobility disorders in individuals with PD.

Two cases of spinal cord extramedullary tumor with positional vertiginous sensation

CONCLUSIONS

We conclude that neck imaging should be carried out for patients with persistent paroxysmal positional vertigo following diagnostic and/or therapeutic maneuvers.

OBJECTIVE

It is sometimes complicated to diagnose patients with vertigo that is transiently induced by head and neck positioning. Neck-vestibular diseases also induce vertiginous sensation with head and neck movement and need to be ruled out for the diagnosis of benign paroxysmal positional vertigo (BPPV).

PATIENTS AND METHODS

Two elderly female patients visited our hospital with complaints of transient vertigo induced by Dix-Hallpike positioning, suggesting posterior canal BPPV. We carried out gadolinium-enhanced neck MRI in both these cases.

RESULTS

The positional nystagmus was not clearly observed or vertiginous sensation did not show any decay during repeated vestibular examination in either case. These cases were finally diagnosed as spinal cord intradural extramedullary tumor (C3-C4) by means of neck MRI.

Posture and equilibrium in orthopedic and rheumatologic diseases

Posture and balance may be affected in many spine or lower-limb disorders. An extensive evaluation including clinical tests and movement analysis techniques may be necessary to characterize how rheumatologic or orthopedic diseases are related to static or dynamic changes in postural control. In lower limbs, unbalance may be related to a decreased stability following arthrosis or ligament injuries at knee or ankle levels, while hip lesions appear less associated with such troubles. Spinal diseases at cervical level are frequently associated with postural changes and impaired balance control, related to the major role of sensory inputs during stance and gait. At lower levels, changes are noticed in major scoliosis and may be related to pain intensity in patients with chronic low-back pain. Whatever the initial lesion and the affected level, improvement in clinical or instrumental tests following rehabilitation or brace wearing provides argument for a close relationship between rheumatologic or orthopedic diseases and related impairments in posture and balance control.

[Cervicoproprioceptive provocation of horizontal and vertical nystagmus in test subjects]

BACKGROUND

The cervico-ocular reflex (COR) has been confirmed in numerous animal experiments. On the other hand, its clinical assessment is disputed. Anteflexion and retroflexion of the head are among the main movements of the atlanto-occipital joint. We investigated whether these head movements produce neck proprioceptive stimulation in the vestibular system.

SUBJECTS AND METHOD

We investigated 50 students under the experimental conditions of strictly cervical provocation. The trunk was rotated, anteflexed, and retroflexed into its end positions for 60 s under video-oculographic control without changing the head-space relationship. During the cervical provocation, horizontal, vertical, or rotational nystagmus within a time window of 5-30 s after the start of the provocation was detected as a target parameter.

RESULTS

The results showed that, compared to the baseline, there was a significant increase in vertical and horizontal nystagmus after the cervical provocation. The horizontal nystagmus reaction, rather than the vertical, was increased significantly by the maximum trunk rotation. In addition, we found a significant amount of vertical rather than horizontal nystagmus under trunk flexion provocation.

CONCLUSION

Under cervical provocation of test subjects, we were able to elicit horizontal and vertical nystagmus (upbeat nystagmus) via cervico-ocular roots. Due to a neck proprioceptive activation of the vestibular system we interpret our result as a "cervico-tonic provocation nystagmus".

Consciously postural sway and cervical vertigo after whiplash injury

STUDY DESIGN

Cross-sectional study of whiplash injury patients with vertigo and healthy volunteers consciously pretending to have postural sway as in malingering.

OBJECTIVE

The aim of this study was to evaluate the postural sway in malingerers by posturography.

SUMMARY OF BACKGROUND DATA

Malingering is not a problem in the majority of cases with whiplash injury and diagnosis should be made carefully. However, some patients with whiplash injury might exaggerate their symptoms or be malingerers because of the potential gain associated with insurance claims. We designed a diagnostic study to screen putative malingerers.

METHODS

Subjects were 20 healthy volunteers who were tested under standing condition (normal group), consciously swaying the body under standing condition like malingerers (pseudomalingering group) and 32 patients who complained of neck pain with vertigo or dizziness after whiplash injury with WAD (whiplash-associated disorders) grade I and II (WAD group). The movement of the center of pressure (COP) was measured using a force platform to quantify postural sway. Static posturography was performed under open and closed eyes. We analyzed (1) total envelop area per unit of time (EAREA), (2) shifting length per second (LNG/TIME), (3) sway pattern, and (4) Romberg rate representing total shifting length under eyes-closed/eyes-open.

RESULTS

In open eyes condition, the values of EAREA and LNG/TIME were significant higher under pseudomalingering than both of the control and WAD groups (P < 0.05). The Romberg rate was 1.30 +/- 0.17, 1.13 +/- 0.19, and 1.83 +/- 0.94 in control, pseudo-malingering, and WAD group, respectively, and was less than 1.0 in 45% of pseudomalingering. There were significant differences in the EAREA, LEN/TIME, and Romberg rate between pseudomalingering and the other 2 groups (P < 0.05).

CONCLUSION

Our results suggest that compared with normal subjects and WAD patients, malingerers are more likely to exhibit a wide EAREA, a long sway length per second, and a low Romberg rate. Malingering must be diagnosed carefully and posturography could be a helpful supplementary tool for differentiating whiplash-associated vertigo from malingering.

Cervical Vertigo—Cervical Pain: An Alternative and Efficient Treatment

OBJECTIVES

Cervical vertigo (CV) is commonly attributed to a disturbed cervical proprioception and is associated with cervical pain (CP). It is assumed to respond to a treatment that improves CP. In a prospective observational study, we examined whether a treatment originally devised for patients with CP could improve CV also in cases without CP.

DESIGN

During a period of 3 years, a total of 238 consecutive patients, 41 patients with CV only, 43 patients with CV and CP, 154 patients with CP only, received the same treatment, which consisted of local anaesthetics applied on average in 8 sessions to a fixed set of epidermal, epithelial, and periosteal locations. Outcome was relief of symptoms measured by a verbal-analogue scale at the end of therapy and on average a year later.

RESULTS

At the end of therapy, 58% of patients with CV responded with complete remissions compared to 41% of patients with CP. At follow-up a year later, there were complete remissions in more than 50% in CV as well as in CP.

CONCLUSIONS

The applied therapy led to complete remissions of long duration in a high percentage of patients with CV even when symptoms of CP were missing. This therapy produced good effects for CP as well. Its neurophysiological basis is discussed and may offer a new approach not only to the treatment of CV and CP but in a general sense also to that of acute, chronic, and neuropathic pain. It needs to be emphasized, however, that this study was not a randomized controlled trial and its encouraging results have to be proved by further research.

[Functional disorders and functional diseases in the region of the upper cervical spine particularly regarding the cervical joints. Current status and clinical relevance]

Functional disorders of the upper cervical spine may be responsible for or the primary cause of persistent complaints following an injury or illness. Functional disorders involving the cervical joints, especially C0/C1 and C1/2 but also the C2/3 junction are of particular clinical relevance. Range of motion assessment is extremely important for the diagnosis of joint disorders. Hypomobility or "blockade" can be diagnosed using special examination techniques that, in many cases, can be extended for direct manual therapy. Periarticular structures involved in these dysfunctional processes, especially muscles and fasciae, must also be examined and treated. Clinical manifestations may include locally restricted muscle extensibility (e.g., trigger points, tension or muscle shortening) with zones of radiating pain as well as referred problems distal to the primary lesion. Functional disorders in the region of the upper cervical spine may be accompanied by various types of reflexive compensatory problems. Although they must be diagnosed separately, these disorders frequently respond to the manual therapy techniques used to treat the underlying functional problem. Even if the exact correlations to functional medicine cannot be scientifically demonstrated in every case, functional assessment and treatment techniques are, in our view, a useful addition to the armamentarium for orthopedic diagnosis and treatment.

Mental rotation of body parts and non-corporeal objects in patients with idiopathic cervical dystonia

Mental rotation of body parts is performed through inner simulation of actual movements, and is likely to rely upon cortical and subcortical systems (e.g. motor and premotor areas and basal ganglia) involved in motor planning and execution. Studies indicate that sensory and motor deficits, such as for example pain, limb amputation or focal hand dystonia, bring about a specific impairment in mental rotation of the affected body parts. Here we explored the ability of patients affected by idiopathic cervical dystonia (CD) to mentally rotate affected (neck) and unaffected (hands and feet) body districts. The experimental stimuli consisted of realistic photos of left or right hands or feet and the head of a young men with a black patch on the left or the right eye. As non-corporeal stimulus the front view of a car with a black patch on the left or the right headlight was used. The stimuli were presented at six different degrees of orientations. Twelve CD patients and 12 healthy participants were asked to verbally report whether the hands or feet were left or right, or whether the patch was on the left or the right eye or headlight. Reaction times and accuracy in performing the laterality tasks on the four stimuli were collected. Results showed that CD patients are slow in mental rotation of stimuli representing body parts, namely hand, foot and head. This abnormality was not due to a general impairment in mental rotation per se, since patients' ability to rotate a non-corporeal object (a car) was not significantly different from that of healthy participants. We posit that the deficit in mental rotation of body parts in CD patients may derive from a defective integration of body- and world-related knowledge, a process that is likely to allow a general representation of "me in the external world".

Neck muscle fatigue and postural control in patients with whiplash injury

OBJECTIVES

To examine if patients with whiplash injury show identifiable increases in neck muscle fatigability and associated increase in postural body sway after contractions of dorsal neck muscles, and if physiotherapy treatment reduces these effects.

METHODS

Sway was measured during stance in 13 patients before and after 5 min of isometric dorsal neck muscle contractions and after recovery, pre- and post-physiotherapy, using a force platform. Amplitude and median frequency of neck muscle EMG were calculated during the contracting period. After each stance trial, patients gave a subjective score of sway.

RESULTS

Pre-treatment, seven patients showed EMG signs of fatigue (increases in amplitude, decreases in median frequency) and increases in sway (eyes closed) after contractions. The other patients showed neither fatigue nor increased sway. Post-treatment, no signs of fatigue or imbalance were recorded in all patients, for the same levels of muscle contraction.

CONCLUSIONS

As in normal human subjects, increases in sway are associated with signs of neck muscle fatigue in some whiplash injury patients. Physiotherapy decreases the susceptibility to fatigue of neck muscles and is an effective choice of treatment of subjective instability and sway.

SIGNIFICANCE

This study demonstrates a pathophysiological link between neck muscle fatigue and impaired postural control, and also that physiotherapy can relieve symptoms and signs of impaired neck muscle function by reducing muscle fatigability.

Head repositioning accuracy in patients with whiplash-associated disorders

STUDY DESIGN

Controlled study, measuring head repositioning error (HRE) using an electrogoniometric device.

OBJECTIVE

To compare HRE in neutral position, axial rotation and complex postures of patients with whiplash-associated disorders (WAD) to that of control subjects.

SUMMARY OF BACKGROUND DATA

The presence of kinesthetic alterations in patients with WAD is controversial.

METHODS

In 26 control subjects and 29 patients with WAD (aged 22-74 years), head kinematics was sampled using a 3-dimensional electrogoniometer mounted using a harness and a helmet. All tasks were realized in seated position. The repositioning tasks included neutral repositioning after maximal flexion-extension, eyes open and blindfolded, repositioning at 50 degrees of axial rotation, and repositioning at 50 degrees of axial rotation combined to 20 degrees of ipsilateral bending. The flexion-extension, ipsilateral bending, and axial rotation components of HRE were considered. A multiple-way repeated-measures analysis of variance was used to compare tasks and groups.

RESULTS

The WAD group displayed a reduced flexion-extension range (P = 1.9 x 10(-4)), and larger HRE during flexion-extension and repositioning tasks (P = 0.009) than controls. Neither group nor task affected maximal motion velocity. Neutral HRE of the flexion-extension component was larger in blindfolded condition (P = 0.03). Ipsilateral bending and axial rotation HRE components were smaller than the flexion-extension component (P = 7.1 x 10(-23)). For pure rotation repositioning, axial rotation HRE was significantly larger than flexion-extension and ipsilateral bending repositioning error (P = 3.0 x 10(-23)). Ipsilateral bending component of HRE was significantly larger combined tasks than for pure rotation tasks (P = 0.004).

CONCLUSIONS

In patients with WAD, range of motion and head repositioning accuracy were reduced. However, the differences were small. Vision suppression and task type influenced HRE.

[Additive treatment for central vestibular vertigo]

We have observed in our own practice that numerous patients with primary symptoms of vertigo exhibit cervical segmental muscular imbalance and increased tension in the masticatory musculature. This is frequently associated with functional blockades, especially in the joints of the head and upper cervical spine. Particularly important are special receptors of the small vertebral joints and muscle insertions at the cervicocranial transition. Evidence indicates that there are neuroanatomic structures between these receptors and the central vestibular and cochlear core area of the brain stem, which can explain the vertigo symptoms as well as the frequently associated tinnitus, headache or otalgia. Therapeutic approaches include interruption of the pathological reflex arcs so that muscle tension can resolve and imbalances are equalized. The nociceptive stimulus to the brain stem and its core centers thus recedes. Deafferentation follows from the reflex zones of the posterior oral cavity in the sense of oral acupuncture. Additional procedures include neural therapeutic injections at acupuncture points at the cervicocranial transition, the ear, and maxillary area as well as needle acupuncture of the head, ear, and hand. In isolated cases, improvement of the vertigo symptoms is noticed as early as after the first treatment session. Among other methods, spinovestibular tests according to Romberg and Unterberger can be employed to objectify treatment results.

Clinical and epidemiological study of vertigo at an outpatient clinic

OBJECTIVES

The main goal of this study was to set up a database of vertigo patients that could serve as a reference for other ENT services treating these pathologies. We present a clinical and epidemiological study of vertigo in an ENT outpatient clinic in 2001 and describe our diagnosis protocol.

MATERIAL AND METHODS

This was a prospective study of 591 patients (18% of the total number of 3283 first visits) controlled and treated at the ENT service of the Hospital Clinic in Barcelona. The main variables studied were sex, age, clinical characteristics and the results of physical and basic instrumental examinations.

RESULTS

After obtaining a clinical history and performing a physical examination, pure-tone audiometry, impedance audiometry and electronystagmography, 394 patients were discharged with a medical report, diagnosis and prescription for treatment. The other 197 patients whom the standard examination was unable to diagnose were referred to a multidisciplinary committee for re-evaluation.

CONCLUSION

A correct diagnosis is essential to ensure adequate treatment and attain an acceptable balance between cost and effectiveness.

Os odontoideum in a patient with cervical vertigo: a case report

Cervical vertebral anomalies are often associated with malformations or traumas, they may be completely asymptomatic and represent an occasional finding in vertigo or can cause severe neurologic complications (ie, compression of the upper cervical spine with myelopathy, epilepsy, or respiratory failure). This clinical case is a patient who came to us for observation for a peripheral harmonic vestibular syndrome, and in whom a malformation of the cervical vertebral joint (os odontoideum) was occasionally found on magnetic resonance imaging.

[The usefulness of craniocorpography in the diagnosis of patients with dizziness and increasing muscle tension in the neck]

By the moment, craniocorpographic record of the Romberg test has been scarcely used in clinical practice. Since craniocorpography is a method for recording oscillations of the head and shoulders, it can show characteristic patterns in patients with vertigo caused by increased muscle tension in the neck. In order to confirm this hypothesis, a prospective comparative study was performed with 329 patients. They were included in three different groups: patients with cervical vertigo, patients with vestibular pathology and a healthy control group. Movements of the head (with static shoulders) are more usual in patients with cervical vertigo (67%) than in those with vestibular pathology (27%) and healthy subjects (31%). With regard to the kind of head oscillations, front-back flexions and oscillations in all directions were the most frequent (36% and 34%, respectively). Nevertheless, the only movements previously reported (cervical rotation or torsion) only were 3% of total head movements in our study. We concluded that static craniocorpography is an useful method in diagnosing vertigo secondary to increased muscle tension in the neck.