November 23, 2016

n=1: Personal Reflection of WAD and Dizziness

Author: Maggie Henjum


Of course, like any annoying patient would do, I spent labor day researching this topic – thus the disclaimer that this is not an area of expertise (nor do I want it to be), but an area of mild interest.

Numerous causes of vertigo exist and need to be ruled out before isolation of cervicogenic dizziness. Although not a comprehensive list, primary concerns include: CNS compromise, chiari malformation, vertebral basilar insufficiency, and benign paroxysmal positional vertigo (BPPV).1 BPPV is probably most commonly caught diagnosis in an orthopedic office, but will present with vestibular nystagmus and can be ruled out with Dix-Hallpike testing. Although noted that this test is only moderately effective at this task with sp = 75%, and sn=79%, leaving us with clinical reasoning to strengthen our differential management.2

Cervicogenic dizziness has been noted as low as 20-58%of patients after whiplash injury and as high as 80-90% of patients.1 Capturing these patients is a challenge, most common outcome tool used in office is the NDI and this tool does not address dizziness. Evaluation of literature is of challenge for the same reason, all improvement’s we are measuring are subjective improvement in symptoms.

Causes of cervicogenic dizziness was impressively reviewed in Kristiansson et. al., they describe this phenomenon as altered afferent input from the following systems: somatosensory subsystem (muscle spindles in deep upper cervical muscles), vestibular subsystem and visual subsystem.6 The somatosensory subsystem controls information from periphery and assists us in perceiving pain, temperature, proprioception and touch. Muscle spindles in deep upper cervical muscles are utilized to regulate neuromuscular performance with joint receptors, and golgi tendon organs to fine tune this information.6 Interestingly enough, Oleary et. al found that fatty replacement into the cervical extensor muscles after WAD, making them less effective at motor and force output.3 Adding into the concept that possibility of strengthening deep neck flexors can improve proprioception, and possibly dizziness. Vestibular subsystem controls postural tone in muscles of trunk and extremities, this provides balance with movement.6Here, otolith system tells us information on the velocity and position of our head during a task and is relayed back for processing – this may prove valuable for a avid skier. Lastly, visual subsystem provides important information as we guide movement. Possible areas of impairment may lie in smooth pursuit, saccadic system or the optokinetic system – dependent on complaint of the patient.6 Quick overview of the three as I needed it as well is: smooth pursuit is where the eye smoothly stabilizes images, saccadic system is the ability of fast eye movement in changing points of focus, and optokietic system stabilizes the image with a moving visual field.6

Management of cervicogenic dizziness is a challenge, and possibly underestimated. After reviewing literature, two interventions I expect to see is management is manual therapy, and joint position error retraining. A 2005 systematic review of manual therapy management of cervicogenic dizziness reviewed 26 trials unfortunately only 1 being an RCT.5 The single RCT by Karlberg et. al, found 12% patients completely resolve dizziness, and 71% of patients with improvement in symptoms.4 Manual therapy is thought to improve mobility of zygapophyseal joints of the upper cervical spine, possibly improving afferent input to decreased dizziness.5 Secondly, is joint position error (JPE) retraining.  Manual therapy has an outcome of improving joint position sense, but also retraining this system is appropriate follow up for an exercises program and JPE may be useful objective measurement.6 JPE is described a measurement of postural instability, where a patient is to sit 90 cm from a wall, a laser is used with eyes open focusing on a target, then closing eyes the patient is to rotate right and return to neutral – a difference of >7.1 cm is considered abnormal.6 This test is performed in rotation, and flexion with measurements compared at each position.

Interesting enough, cervicogenic dizziness research is a challenge to come by, thus the egocentric need for me to see if I can improve subjective dizziness – or affect headaches with only retraining afferent input to my superior colliculus – or possibly an elaborate placebo. Regardless, interesting topic to review but lack of strong literature leaves me to rely on expertise of my occupational therapist – yikes.


Original post: September 1, 2013



1) Timothy W. Flynn, PT, PhD (2013, August). Management of Cervicogenic Dizziness. Lecture conducted through EIM.

2) Halker RB, Barrs DM, Wellik KE, Wingerchik DM, Demaerschalk BM. Establishing a Diagnosis of Benign Paroxysmal Positional Vertigo Through the Dix-Hallpike and Side-lying Maneuvers: A Critically Appraised Topic. Neurologist. 2008; 14:201-204.

3) O’Leary, S., Falla, D., Elliott, J. M., & Jull, G. (2009). Muscle dysfunction in cervical spine pain: implications for assessment and management. The Journal of orthopaedic and sports physical therapy, 39(5), 324–33. doi:10.2519/jospt.2009.2872

4) Karlberg M, Magnussen M, Malmstrom E-M, Melander A, Moritz U. Postural and symptomatic improvement after physiotherapy in patients with dizziness of suspected cervical origin. Archives of Physical Medicine and Rehabilitation 1996;77:874–82.

5) Reid, S. a, & Rivett, D. a. (2005). Manual therapy treatment of cervicogenic dizziness: a systematic review. Manual therapy, 10(1), 4–13. doi:10.1016/j.math.2004.03.006

6) Kristjansson, E., & Treleaven, J. (2009). Sensorimotor function and dizziness in neck pain: implications for assessment and management. The Journal of orthopaedic and sports physical therapy, 39(5), 364–77. doi:10.2519/jospt.2009.2834