Patient education is one of the most critical aspects of chiropractic care. Evidence-based physicians must use the most up-to-date research to guide their case management and patient education. Unfortunately, some diagnoses have complex etiologies. Many patients don’t comprehend medical terminology. Did you know that the average American reads at a sixth-grade level? Those patients will often nod with approval during your report of findings, only to hide their lack of understanding. Explaining a specific diagnosis to a variety of patients regardless of their educational level poses a challenge.
Watch Dr. Steele’s lay explanation of Cervicogenic Vertigo.
Dizziness and vertigo account for over eight million primary care visits in the US each year. Disequilibrium may arise from one or multiple anatomical structures. “Central” origins include the brain stem, cerebellum, or other supratentorial structures (or the vasculature supplying those tissues). “Peripheral” origins include the vestibular, visual, and spinal proprioceptive systems.
The most common cause of vertigo is from a peripheral source: the cervical spine. Proprioceptive input from the cervical spine plays a critical role in the maintenance of balance. Most researchers ascribe to an altered “mechanoreceptive” theory as the origin to cervicogenic vertigo. The upper cervical (C0-3) facet joints are highly innervated, supplying up to 50% of all cervical proprioceptive input. Abnormal stimulation of the articular capsule and muscle spindle mechanoreceptors from joint dysfunction or muscle hyperactivity provides conflicting input with visual and vestibular afferents. This sensory mismatch between visual, vestibular, and cervical mechanoreceptive input “confuses” the brain into a temporary state of dizziness.
New research from Peng (2018) implicates cervical spine degeneration as a trigger for vertigo.
“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 hypertonic 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.” (1)
The following tests provide valuable insight to help differentiate two common causes of vertigo.
Perform this test with the patient seated on an exam stool. While the clinician firmly stabilizes the patient’s head with both hands, the patient rotates their entire trunk on the stool. The patient is asked to report any vertigo while the clinician observes for nystagmus. Repeat in the opposite direction. Reproduction of vertigo or nystagmus is a positive test, suggesting cervicogenic vertigo.
Perform this test with the patient seated on an exam table, legs extended. The clinician rotates the patient’s head 45 degrees and quickly brings the patient into a supine position with their head extended off of the table to 30 degrees. Hold this position for at least 15 seconds and the patient is asked to report any vertigo while the clinician observes for nystagmus. Return the patient to the upright, seated posture and repeat on the opposite side. Reproduction of vertigo or nystagmus is a positive test, suggesting BPPV.
BPPV will require different exercises and treatments, and some cases may require co-management with and EENT. True cervicogenic vertigo typically responds to chiropractic manipulation, myofascial release, and rehab exercises. These patients are often home runs that would otherwise fail medical management. Medicine may be a good treatment option for many chemical problems, but cervicogenic vertigo is a mechanical problem.
Cervicogenic dizziness is a diagnosis of exclusion, as there is no pathognomonic test to confirm its presence. Clinicians should be particularly astute and unhurried when evaluating vertigo. The common co-existence of vertigo and upper cervical discomfort has the potential to lull clinicians into a dangerous state of diagnostic complacency. Falsely assuming that someone with concurrent dizziness and neck pain is suffering from cervicogenic vertigo, without ruling out other potentially threatening causes of dizziness, could end in disaster.
We must spend the time to classify and educate patients the first time to obtain the best possible patient outcomes. Check out the ChiroUp condition reference section to review the most up-to-date research on vertigo including clinical pearls, rehab protocols, and treatment options. Then practice with confidence knowing that your patients are armed with the best exercises and patient education. If you’re not yet a ChiroUp subscriber, click here to try it now.
About the Author
Dr. Brandon Steele
Dr. Steele began his career at The Central Institute for Human Performance. Dr. Steele has trained with experts including Pavel Kolar, Stuart McGill, Brett Winchester, and Clayton Skaggs. He has been certified in Motion Palpation, DNS, ART, and McKenzie Therapy. Dr. Steele lectures extensively on clinical excellence and evidence-based musculoskeletal management. He currently practices in Swansea, IL and serves on the executive board of the ICS.