Cervicogenic Dizziness (CGD) is a controversial diagnosis and remains a diagnosis of exclusion, meaning that other potential causes of dizziness have to be ruled out first. There are many causes of dizziness, including many medications, vision problems, and vestibular, cardiovascular, metabolic, neurological, and psychological conditions. Therefore, a systematic process to differentiate between cervicogenic and other causes of dizziness is necessary.

CGD can be characterized by the presence of:

• imbalance,

• unsteadiness,

• disorientation,

• neck pain,

• limited cervical range of motion (ROM),

• and may be accompanied by a headache.

With CGD, dizziness should be closely related to changes in cervical spine position or cervical joint movement. It can be associated with a whiplash injury, or inflammatory, degenerative, or mechanical dysfunctions of the cervical spine.

For CGD to be considered, the patient should have a history of neck pathology and also experience dizziness that has a close temporal relationship with the onset of cervical spine symptoms.

Potential Causes of Cervicogenic Dizziness

The proprioceptive inputs from the neck play an important role in head-eye coordination and postural control. Neck proprioception from important structures provides crucial information about head movements relative to the trunk:

• Neck muscles, especially in the suboccipital region, are richly endowed with spindles, which have a complex sensory and motor innervation within the muscles

• Mechanoreceptive nerve endings in the facet joint capsules provide proprioception and pain sensation in the cervical spine

• Interacting signals with the vestibular and visual systems to stabilize the eyes, head, and posture

Potential physiological mechanisms of CGD that can result in a sensory mismatch include:

• Altered upper cervical somatosensory input associated with neck problems

• Disruption of the normal afferent signals from the upper cervical proprioceptors (including joint capsules) to the vestibular nucleus resulting in an inaccurate depiction of head and neck orientation in space

• Abnormal afferent signals associated with pain

The cervical spine can become damaged due to direct trauma, muscular fatigue, or degeneration. Cervical spine pathology can disrupt the connections between the cervical dorsal roots and the vestibular nuclei that contribute to the perception of balance and postural adjustments, leading to complaints of dizziness or disequilibrium.

Symptoms Associated With Cervicogenic Dizziness

Dizziness and cervical symptoms (i.e. neck pain) should coincide. The neck pain can occur at rest, with movement, or with palpation. Symptoms caused by CGD should be exacerbated by movements that elicit neck pain, and fatigue, anxiety, and stress are found to be common precipitating factors for the exacerbation of symptoms.

The duration of symptoms is an important aspect of the subjective history that helps differentiate CGD from other pathologies. The duration of symptoms for CGD can widely range from days to months to years. Each episode of dizziness typically lasts minutes to hours.

CGD is not usually associated with:

• vertigo,

• tinnitus,

• aural fullness,

• hearing loss,

• or migraines.

Assessment of Cervicogenic Dizziness

After ruling out other potential competing pathologies, the assessment for CGD includes the following:

Cervical spine screening:

• All patients should have a rudimentary cervical spine examination prior to vestibular testing, as the vestibular assessment may need to be modified to limit the head movements to the available cervical ROM.

Vestibular assessment:

• The vestibular assessment includes an oculomotor evaluation and testing of the vestibulo-ocular reflex (VOR). The presence of nystagmus is clinically useful to determine if the vestibular system is involved and can help to rule out CGD.

Testing to differentiate between CGD and dizziness from vestibular disorders:

• The Head-Neck Differentiation Test: Provocation of dizziness with trunk rotation under a head stabilized in space implicates the cervical spine, whereas dizziness with head and trunk rotation together (en bloc rotation) indicates a vestibular component to the patient’s symptoms.

• The Cervical Joint Position Error Test also has good diagnostic value for ruling out the diagnosis of CGD. Chronic neck pain is associated with impaired cervical proprioception, which is affected by CGD.

Cervical spine assessment:

• The cervical spine assessment includes a manual examination and assessment of postural alignment and control. Postural alignment and control should be assessed because postural impairments are commonly seen in cases of CGD, especially in cases with neck pain from a whiplash injury.

It is possible for patients to have both CGD and another cause of dizziness, such as a vestibular pathology. In this case, the clinician should thoroughly address the other cause(s) of dizziness with the appropriate interventions, before treating the patient for CGD if the dizziness persists.

Treatment of Cervicogenic Dizziness

1. Manual therapy:

   It has been suggested that the management of CGD should be the same as for cervical pain. Manual therapy assists with normalizing disturbances to the afferent input from deep neck proprioceptors, which in turn reduces sensory mismatch. This also restores the ability of the sensory systems to utilize the internal vestibular orienting information associated with head and neck position in space, resulting in a decreased sensation of dizziness and disequilibrium.

2. Vestibular rehabilitation:

   Stability and posture of the cervical spine are achieved by a combination of reflexes mediated by cervical, vestibular, and visual input. The cerebellum plays an important role in integrating this sensory information. When cervical afferent input is affected, vestibular rehabilitation may improve the inputs from the vestibulo-cerebellar system to compensate for the altered cervical input and adapt to the sensory mismatch.

3. Sensorimotor rehabilitation

   Sensorimotor rehabilitation involves training cervical joint position sense through head-neck relocation exercises. A laser headband can be used for visual feedback. The training conditions can be modified and progressed based on response to the exercises, such as performance and/or symptom provocation. For example, the patient can perform the exercise lying down, if it causes dizziness, or can progress to standing on a soft surface if the exercise becomes easier.

4. Exercise therapy

   Exercises are prescribed to target muscular control and endurance. Exercises usually begin with activation of the deep cervical stabilizing muscles, then progress to retraining all of the cervical muscles in a variety of postures. The aim is usually to develop technique and low load endurance before integrating these muscles into more function-specific exercises.

Sources:

Chu, E. C., Chin, W. L., & Bhaumik, A. (2019). Cervicogenic dizziness. Oxford Medical Case Reports, 2019(11), 476-478. doi:10.1093/omcr/omz115

Reiley, A. S., Vickory, F. M., Funderburg, S. E., Cesario, R. A., & Clendaniel, R. A. (2017). How to diagnose cervicogenic dizziness. Archives of Physiotherapy, 7(1). doi:10.1186/s40945-017-0040-x