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.

Dizziness, unsteadiness, visual disturbances, and postural control: implications for the transition to chronic symptoms after a whiplash trauma

STUDY DESIGN

Synthesis and application of research.

OBJECTIVE

To provide a framework to consider the role of signs and symptoms of postural control disturbance in the transition to chronicity after a whiplash trauma.

SUMMARY OF BACKGROUND DATA

Dizziness is one of the most frequent complaints in those with persistent pain after a whiplash trauma and is often associated with postural control disturbances.

METHODS

Focus paper to review the causes, management, onset, and relationships of such signs and symptoms after a whiplash trauma to explore the role they may have in the transition to chronicity.

RESULTS

Contemporary literature suggests these signs and symptoms are often, but not always, aligned with those with significant neck pain and disability and have been related to a poorer prognosis. There are obvious links between the cervical proprioceptors and the musculoskeletal system, but links to the autonomic nervous, vestibular, and visual systems and influence on pain modulation are important. Postural control may have potential to alter other systems and affect pain and should be considered as one of the processes that might influence the transition to chronicity after a whiplash trauma. Future research should monitor the effect that addressing abnormal cervical afferent input has on not just dizziness and postural control but other symptoms such as altered pain processing and psychological distress.

CONCLUSION

The causes of transition into chronicity after a whiplash trauma are present early and appear to be multifactorial. Pain sensitivity and psychosocial distress have recently been considered but postural deficits and the symptom of dizziness also appear to have a role.It is recommended that future research address these issues to further the understanding of the transition to chronicity after a whiplash trauma.

Sustained natural apophyseal glides (SNAGs) are an effective treatment for cervicogenic dizziness

<Cervicogenic dizziness is dizziness described as imbalance occurring together with cervical pain or headache. This study aimed to determine the efficacy of sustained natural apophyseal glides (SNAGs) in the treatment of this condition. A double-blind randomised controlled clinical trial was undertaken. Thirty-four participants with cervicogenic dizziness were randomised to receive four to six treatments of SNAGs (n=17) or a placebo of detuned laser (n=17). Participants were assessed by a blinded assistant before treatment, after the final treatment and at 6- and 12-week follow-ups. The primary outcome measures were severity of dizziness, disability, frequency of dizziness, severity of cervical pain, and global perceived effect; balance and cervical range of motion were secondary measures. At post-treatment, 6- and 12-week follow-ups compared to pre-treatment, the SNAG group had less (P<0.05) dizziness, lower (P<0.05) scores on the Dizziness Handicap Inventory (DHI), decreased (P<0.05) frequency of dizziness, and less (P<0.05) cervical pain. The placebo group had significant (P<0.05) changes only at the 12-week follow-up in three outcome measures: severity of dizziness, DHI, and severity of cervical pain. Compared to the placebo group at post-treatment and 6-week follow-up, the SNAG group had less (P<0.05) dizziness, lower (P < or =0.05) scores on DHI, and less (P<0.05) cervical pain. Balance with the neck in extension improved (P < or =0.05) and extension range of motion increased (P<0.05) in the SNAG group. No improvements in balance or range of motion were observed in the placebo group. The SNAG treatment had an immediate clinically and statistically significant sustained effect in reducing dizziness, cervical pain and disability caused by cervical dysfunction.

Manual therapy treatment of cervicogenic dizziness: a systematic review

Dizziness is a common and often disabling disorder. In some people the cause of their dizziness is pathology or dysfunction of upper cervical vertebral segments that can be treated with manual therapy. The aim of the present study was to systematically review the literature on the manual therapy treatment of patients with cervicogenic dizziness, by identifying and evaluating both randomized controlled trials (RCTs) and non-RCTs (controlled clinical trials and non-controlled studies). Seven electronic databases were searched up to July 2003, article reference lists were screened and an expert panel elicited to obtain relevant trials. Nine studies met the inclusion criteria and key data was extracted. Two reviewers assessed the validity of the studies using the Cochrane format and found that all studies had low methodological quality. However, a consistent finding was that all studies had a positive result with significant improvement in symptoms and signs of dizziness after manual therapy treatment. Therefore, Level 3 evidence for manual therapy treatment of cervicogenic dizziness was obtained indicating it should be considered in the management of patients with this disorder provided there is evidence of improvement. This review has identified the need for further RCTs of acceptable methodological quality.

Manipulation and mobilisation for mechanical neck disorders

BACKGROUND

Neck disorders are common, disabling, and costly. The effectiveness of manipulation and mobilisation remains unclear.

OBJECTIVES

To assess whether manipulation and mobilisation, either alone or in combination with other treatments, relieve pain or improve function/disability, patient satisfaction, and global perceived effect in adults with mechanical neck disorders (MND).

SEARCH STRATEGY

Computerised bibliographic databases including CENTRAL, MEDLINE, EMBASE, MANTIS, CINAHL, and ICL, were searched without language restrictions from their respective starting dates to March 2002.

SELECTION CRITERIA

The studies had to be randomised (RCT) or quasi-randomised and investigate the use of manipulation or mobilisation as a treatment for mechanical neck disorders.

DATA COLLECTION AND ANALYSIS

Two independent reviewers conducted citation identification, study selection, data abstraction, and methodological quality assessment. Using a random effects model, relative risk and standardised mean differences were calculated. The reasonableness of combining studies was assessed on clinical and statistical grounds. In the absence of heterogeneity, pooled effect measures were calculated.

MAIN RESULTS

Of the 33 selected trials, 42% were high quality trials. Single sessions of manipulation or multiple sessions (3 to 11 weeks) of manipulation or mobilisation, or manipulation and mobilisation showed a nonsignificant benefit in pain relief when assessed against placebo, control groups or other treatments for acute/subacute/chronic MNDs with or without headache. There was strong evidence of benefit favouring multimodal care over a waiting list control for pain reduction [pooled SMD -0.85 (95% CI: -1.20 to -0.50)], improvement in function [pooled SMD -0.57 (95% CI: -0.94 to -0.21)] and global perceived effect [SMD -2.73 (95% CI: -3.30 to -2.16)] for subacute/chronic MND with or without headache. The common elements in this care strategy were mobilisation and/or manipulation plus exercise. There was moderate evidence of no difference in effect when multimodal care was compared to various other treatments.

REVIEWER'S CONCLUSIONS

Multimodal care has short-term and long-term maintained benefits for subacute/chronic MND with or without headache. The common elements in this care strategy were mobilisation and/or manipulation plus exercise. The evidence did not favour manipulation and/or mobilisation done alone or in combination with various other physical medicine agents; when compared to one another, neither was superior. There was insufficient evidence available to draw conclusions for neck disorder with radicular findings. The added benefit of exercise needs to be further explored. Factorial design would help determine the active treatment agent(s) within a treatment mix. Phase II trials would help identify the most effective treatment characteristics and dosages. Greater attention to methodological quality is needed.

Cervicogenic dizziness: a review of diagnosis and treatment

The diagnosis of cervicogenic dizziness is characterized by dizziness and dysequilibrium that is associated with neck pain in patients with cervical pathology. The diagnosis and treatment of an individual presenting with cervical spine dysfunction and associated dizziness complaints can be a challenging experience to orthopaedic and vestibular rehabilitation specialists. The purpose of this article is to review the incidence and prevalence, historical background, and proposed pathophysiology underlying cervicogenic dizziness. In addition, we have outlined the diagnostic criteria, evaluation, and treatment of dizziness attributed to disorders of the cervical spine. The diagnosis of cervicogenic dizziness is dependent upon correlating symptoms of imbalance and dizziness with neck pain and excluding other vestibular disorders based on history, examination, and vestibular function tests. When diagnosed correctly, cervicogenic dizziness can be successfully treated using a combination of manual therapy and vestibular rehabilitation. We present 2 cases, of patients diagnosed with cervicogenic dizziness, as an illustration of the clinical decision-making process in regard to this diagnosis.