Can anyone describe an MWM for cervical origin dizziness?

Hi All,

I'm wondering if anyone can direct me to an accurate description of how to MWM (Mobilisation with Movement) Cx for cervicogenic dizziness/lightheadedness ...my client has had neuro r/v all clear, negative Hall-Pike's, nil VBI, negative Cx quadrants, can only get reproducible dizziness on lateral approach or AP approach right C5/6 in supine. Highly hyperalgaesic Cx musculature and anxiety (had the problem for >14months, onset post Cx Mobs with another physio), Carotid small reported blockage but clinically insignificant (on doppler), bp is stable. Gait affected with left hand drift, full brain and cerebellar CT showed no probs, cranial nerves all intact on testing. Client has been sent to me as "last resort", nil response to gapping rotation approach to L side mobs and I am now thinking I'd like to MWM the Cx as it's a gentle approach but would like a couple of alternative techniques if anyone out there can be descriptive enough. - or if there's a guru out there with another idea.

Thanks for the input.

msk101

hi
there was an article in manual therapy journal in 2008 related to mulligen's technique for cervical dizziness .

Can you clarify what the person describes when reporting "dizziness". How long is the duration, how quick onset, body/head positions to agg/ease etc. Is it true-vertigo (rotational spinning of room or person) or non-vertigo dizziness (light headed, unsteady etc) ? If its true vertigo then its unlikely to be cervical in origin. Are there any other symptoms present e.g. tinnitus/HA/nystagmus etc?.

C5-6 seems a little low for reproduction of classical articular cervicogenic symptoms and an accurate upper Cs quad should be positive if cervical in origin.

Dear msk101:

Your case is interesting and I will be interested in the replies you obtain.

With all indications as negative, you have been thorough.

I once had a patient where the muscles attaching to the mastoid process were in excess tonus and the person had dizziness and conditions where nothing made sense. When I treated the digastric, some of the symptons abated. The other muscles attaching to the mastoid may have been a factor also as all were treated, but the digastric made the most difference. I cannot explain it, but it worked.

Hope that this is helpful.

Best regards,

Neuromuscular.

HI all,
Thanks for the input so far. Dizziness is described as lightheadedness, not true vertigo. This is a constant thing with no discernable aggs/eases although she does tend to lie-sit slowly just habitually now since this has been going on for 14 months. Nil VBI signs (no nystagmus, or nausea, nil loss of facial control, nil auditory symptoms etc). Client is very unsteady on her feet and tends to wall-walk or furniture prop but does not state that the room is spinning or rotational at all.

In my last treatment I worked primarily on right side (sore side) scalenes, lev scap and anterior cervical musculature and will review client tomorrow to see if it helped! The muscles were indeed extremely tense and painful, and I was interested in Neuromuscular's story (but only read this after the last treatment tho!) but I had to be quite gentle as client has relatively low pain threshold (or i'm just a brutal physio... which might occasionally be the case!). So it will be a slowly slowly approach (or my dear client might not come back again!) and we'll see and update later.

Cheers
msk101

Dear msk101,

The best explanation tht I have come across on the effect of the muscles which attach to the mastoid to dizzines or vertico is that these can induce referred pain into the ear and thus upset the balance mechanism of the ear.

I must admit that my experience has been only on a few patients, so I cannot say if this is common or I just had the few select patients.

As I said, I will look forward to the other replies to this and how your own outcome is on the patient at hand.

Best regards,

Neuromuscular

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Dear msk101,

The best explanation that I have come across on the effect of the muscles which attach to the mastoid to dizzines or vertico is that these can induce referred pain into the ear and thus upset the balance mechanism of the ear.

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i wonder how the muscles induce pain into ear.i would like to know the reference

[QUOTE=linbin;24393]

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Originally Posted by neuromuscular

Dear msk101,

The best explanation tht I have come across on the effect of the muscles which attach to the mastoid to dizzines or vertico is that these can induce referred pain into the ear and thus upset the balance mechanism of the ear.

i wonder how the muscles induce pain into ear.i would like to know the reference

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Dear linbin:

The best resource on this is the manuals by Janett Travell on the pain refferal patterns of the muscular systems. There are two manuals. I believe the title of the manuals is Myofascial Pain & Dysfunction: the trigger point manual.

Referred pain by muscles is by far the most overlooked problem. Visceral pain referral is used extensively by the medical practitioner, but muscular pain referral is not

Hope that this is helpful.

Best regards,

Neuromuscular

hi buddy
thanks a lot for the reply .i will check the book mentioned.
i agree with you that somatic referred pain are not extensively studies compared to visceral refered one

Has she been seen by a neurologist? Left arm drift is a bit weird - does she have any other cerebellar signs (abnormal Finger-nose-finger, heel-shin, rapid alt. movements, +ve Romberg)? A Ct does not give particularly good images of the brainstem and cerebellum but I suppose you would see if she had a stroke 14 months ago.

good luck!

Hi,
after reading through all the comments, I am still wondering, what the original problem was, e.g. why did your patient had cervical mob in the first place?
To me her presentation is similar to that of a mild TBI.
She does display clear neurological symptoms, so I really am surprised, that her neurology review was all clear.
Has she had a full oculomotor and vestibular Physio assessment?
Cheers,
Fyzzio

HI All,

Yes, client has been seen by a neuro. I sent her back for a contrast MRI and am now hoping to hear something on that. also has had a full neuro assessment which, other than the light headedness and left drift when walking, is within normal range.

Something's not right for sure (understatement of the century).

Original Cx mob from what i can tell (i was not the treating physio) was post-shoulder surgery and prolonged sling use which resulted in Cx tension and pain. Onset of current symptoms 2 days later. presented to me 13 months later after referral from the neurologist to me.

I have seen the Travell and Simons trigger point info and have done some work on the musculature of the Cx but to no avail. other than better Cx ROM. but no symptom resolution. I am more and more thinking cerebellar infarct (perhaps the original mobs threw off a clot from the carotid artery????) and have referred back to the neuro with a long list of things i've done and want checked out more thoroughly.

oh well... you win some and lose some... fortunately the balance is generally in favour of the winning but not in this case.

Thanks to everyone for their ideas and suggestions.

Msk101 :)

Sorry the referred pain or paraesthesia of the work of Janett Travell et al did not work. There may be more involved. Hope that you find some other helpful info.

However, if nothing else does turn up, see if another muscle that you did not try may be a factor. It may be one that is not directly attached to the mastoid.


Best regards,

Neuromuscular.

I'm actually very curious about this case b/c I believe I have the same problem. I dislocated my shoulder a little over a year ago and after weeks in a sling I began to have cervical stiffness. I saw a chiro and began having severe bouts of dizziness. I stopped being adjusted and the dizziness appeared to go away, but still returns intermittently. Something just "doesn't feel right" with my neck and I sit, stand, walk, etc. very hesitantly for fear of provoking the dizziness. I was tested for vertigo, mri's (brain/shld), catscans, and everything came back negative but I still experience these bouts of dizziness. My eyes begin to hurt a little and it feels like everything gets cloudy and sometimes my neck will "pop" like a knuckle cracking causing the symptoms to diminish instantly. One time my SCM completely locked up so I try to do soft tissue on that, but I honestly feel like trigger pt. on Levator Scap. on the non-injured side (probably from compensatory tightness for the months post-injury) releases the most tension in my neck. I still think i have an instability issue, but I've seen so many doctor's and find it hard to believe they all would've missed this. I work for a physical therapy company, so it's embarassing that I cannot solve my own problem. Try working on her Levator mm. Anybody have any other ideas???

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Originally Posted by atcjoeyb

I'm actually very curious about this case b/c I believe I have the same problem. I dislocated my shoulder a little over a year ago and after weeks in a sling I began to have cervical stiffness. I saw a chiro and began having severe bouts of dizziness. I stopped being adjusted and the dizziness appeared to go away, but still returns intermittently. Something just "doesn't feel right" with my neck and I sit, stand, walk, etc. very hesitantly for fear of provoking the dizziness. I was tested for vertigo, mri's (brain/shld), catscans, and everything came back negative but I still experience these bouts of dizziness. My eyes begin to hurt a little and it feels like everything gets cloudy and sometimes my neck will "pop" like a knuckle cracking causing the symptoms to diminish instantly. One time my SCM completely locked up so I try to do soft tissue on that, but I honestly feel like trigger pt. on Levator Scap. on the non-injured side (probably from compensatory tightness for the months post-injury) releases the most tension in my neck. I still think i have an instability issue, but I've seen so many doctor's and find it hard to believe they all would've missed this. I work for a physical therapy company, so it's embarassing that I cannot solve my own problem. Try working on her Levator mm. Anybody have any other ideas???

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Dear atcjoeyb,

If you have ruled out other factors, the refered pain patterns or paraesthesthesia effect of tigger points, as it is not always "pain" that is referred, can have a great effect.

The levator scap. can cause pressure to and distortion to the upper cervical bones. If the trigger pt. of the levator scap. does not correct it, then consult Janett Travell's manuals for other possibilities. The other option is a NUCCA chiropractor, but that is usually not necessary, if you can find the specific muscular distress.

Hope that this is helpful.

Best regards,,

neuromuscular.

actjoey, since you had a chiropractic manipulation, that takes you into a different aetiology than msk101's patient, who aside from cervical mobilisations, had no 'trauma' to the cervical region, therefore your problems are most likely entirely different.
msk101- is it possible your patient has vestibular migraine?

With regards to the original case reported on this post (msk101's patient) I think the reality needs to be accepted that you are chasing a diagnosis that will not be found. From your reports there is every indication that if there was a mild initial neurological lesion evidence of this does not exist or can no longer be seen. The initial "mechanism of injury" (if it can be called that) does not remotely fit with the patient's subsequent symptoms, if for no other reason than it was 2 days following the mobilization before symptoms started. Just because the patient attributed her PT session as the cause of her dizziness does not make it so, and given the descriptions you have provided it looks like no practitioner she has seen has told her this. The fact that mobilizations at C56 on one side in essentially one direction reproduces her symptoms (mildly, as I understood it anyways) sounds alot more like a "learned response" rather than a comparable sign. It just doesn't fit with anything else.

Her severe anxiety, cervical hypersensitivity and hyper-vigilance (desperately aware of the slightest onset of her symptoms, and extremely protective of herself when experiencing them) vastly more lend themselves towards the onset of what would usually be called a pain disorder along the lines of what you would see in a chronic pain management population, although in this case it is a "lightheadness disorder". You don't mention regular falls or true loss of balance despite her residual symptoms, which likely indicates this patient is capable of more than she realizes (I admit I am assuming a significantly level of disability given the way you describe her overall status).

I am genuinely sorry this patient continues to experience these symptoms, but she (and yourself as her rehabilitative practitioner) need to target the obvious secondary symptoms that in all likelihood are magnifying her primary symptoms. Talk to anyone who works in chronic pain management or disability, and they will provide for you countless examples of patient's secondary issues greatly magnifying their primary problem.

At best there was a minor neurological incident that symptomatically did not fully resolve and they can do nothing about medically 14 months after the fact. At worst she had some transient symptoms that she latched on to and now uses to define her existence.

The best treatment you can do for her is stopping investigating (all it's doing is wasting time and over-medicalizing the situation), get her to see a counsellor/psychologist to teach her how to work herself out from her anxious and hyper-vigilant state, and get her to see a PT with a specialization in balance and vestibular disorders so she can re-build her balance (or confidence in her balance). That way she can get on with her life instead of waiting for a magic answer and solution that is unlikely to come.

Anyone else out there think this?

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Originally Posted by constantwanderer

The best treatment you can do for her is stopping investigating (all it's doing is wasting time and over-medicalizing the situation), get her to see a counsellor/psychologist to teach her how to work herself out from her anxious and hyper-vigilant state, and get her to see a PT with a specialization in balance and vestibular disorders so she can re-build her balance (or confidence in her balance). That way she can get on with her life instead of waiting for a magic answer and solution that is unlikely to come. Anyone else out there think this?

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I would have to say that this might be in part some of the issue. Not sure anyone has mentioned her age anywhere? Also what medications is she on (The full set and their uses). Often meds. will cause the symptoms, if not in isolation, but in combination. I think we should ask for a list of those as well please :)

Also is she suggesting in anyway there was negligence in the first instance? As you are in Australia I would see if there are any travelling courses on 'balance' by Professor Nancy Low Choy. She is amazing and this was one of the most interesting post grad courses I have done.

Did you assess upper thoracic vertebras?

Quote:

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Originally Posted by constantwanderer

With regards to the original case reported on this post (msk101's patient) I think the reality needs to be accepted that you are chasing a diagnosis that will not be found. From your reports there is every indication that if there was a mild initial neurological lesion evidence of this does not exist or can no longer be seen. The initial "mechanism of injury" (if it can be called that) does not remotely fit with the patient's subsequent symptoms, if for no other reason than it was 2 days following the mobilization before symptoms started. Just because the patient attributed her PT session as the cause of her dizziness does not make it so, and given the descriptions you have provided it looks like no practitioner she has seen has told her this. The fact that mobilizations at C56 on one side in essentially one direction reproduces her symptoms (mildly, as I understood it anyways) sounds alot more like a "learned response" rather than a comparable sign. It just doesn't fit with anything else.

Her severe anxiety, cervical hypersensitivity and hyper-vigilance (desperately aware of the slightest onset of her symptoms, and extremely protective of herself when experiencing them) vastly more lend themselves towards the onset of what would usually be called a pain disorder along the lines of what you would see in a chronic pain management population, although in this case it is a "lightheadness disorder". You don't mention regular falls or true loss of balance despite her residual symptoms, which likely indicates this patient is capable of more than she realizes (I admit I am assuming a significantly level of disability given the way you describe her overall status).

I am genuinely sorry this patient continues to experience these symptoms, but she (and yourself as her rehabilitative practitioner) need to target the obvious secondary symptoms that in all likelihood are magnifying her primary symptoms. Talk to anyone who works in chronic pain management or disability, and they will provide for you countless examples of patient's secondary issues greatly magnifying their primary problem.

At best there was a minor neurological incident that symptomatically did not fully resolve and they can do nothing about medically 14 months after the fact. At worst she had some transient symptoms that she latched on to and now uses to define her existence.

The best treatment you can do for her is stopping investigating (all it's doing is wasting time and over-medicalizing the situation), get her to see a counsellor/psychologist to teach her how to work herself out from her anxious and hyper-vigilant state, and get her to see a PT with a specialization in balance and vestibular disorders so she can re-build her balance (or confidence in her balance). That way she can get on with her life instead of waiting for a magic answer and solution that is unlikely to come.

Anyone else out there think this?

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Dear constantwonderer:

I am a little cautious of inferring that one has a psychosis or such. The idea of medication side effects is good.

I was told that I was a hypercondriac when I had low back pain at a young age. The medical people sent me to a surgeon who specialized in the low back. he told me that I would be in a wheel chair in ten years unless I consented to his surgery. That was some stressful to a 20 year old person.

I did not have the surgery and am not in a wheel chair some thirty years later, because I went to a sports therapist trained in Germany, although he was practicing in Canada.

People in pain are stressed out.! What often happens is that we look in the areas of our endeavor and may miss something.

We have to take some of the responsibility. However, we cannot get every case and that is too bad.

Hopefully something can be done for both of these people.

Best regards,

Neuromuscular

Dear constantwonderer,
Thank you for your post, I was thinking along exactly the same lines. Sometimes we can be so keen to try and help someone we forget to ask the main question: are manual/passive techniques the best approach for this patient? My gut feeling (which it has to be in this case without face to face interviewing) is that this patient needs help by gradually challenging some learnt responses. This in no way is disputing the reality of her symptoms or calling her neurotic. May be she just requires a different approach? Neuroplasticity may explain and help treat some of her symptoms.
Regards,
Monkey

Hello.

I just stumbled on this thread and did not read all of it so forgive me if I'm missing something. But, cervicogenic dizziness (CD) is a very real diagnosis. It is not necessarily caused by anxiety or depression.

It was first described in 1955 by Ryan and Cope under the term ‘cervical vertigo.’ Experimentally induced cervicogenic dizziness was later elicited via anesthetic injection in the necks of normal subjects (de Jong et al. 1977), further proving the neck to be one of the possible sources of dizziness. More specifically, mechanoreceptors of the neck have been implicated as a contributing cause of disequilibrium (Wyke 1979). Some people think this occurs because there is a direct (though minor) link between the neck and vestibular system. So, when neck dysfunction occurs there is (in theory) a mismatch of information going into the vestibular system from the vestibular organs and the neck which results in dizziness.

In the 1990's there was investigation into cervical kinesthetic sensibility (CKS) and the effects of the CKS retraining exercises on improved position sense, neck pain, and cervical ROM (Revel et al. 1991, Revel et al. 1994, Heikkilä et al. 1998). If you look up the Revel articles there are so good exercise ideas for treating cervicogenic dizziness.

It is known that whiplash (Wrisley et al. 2000, Borg-Stein 2001, Endo et al. 2006), cervical spondylosis (Ryan and Cope 1955, Reid et al. 2008), hypomobility (Reid et al. 2008), hypermobility (Malmström 2007), and poor dynamic and postural control (Alund et al. 1992, Heikkilä et al. 1998, Malmström 2007) can all contribute to CD. Impairment based musculoskeletal treatment (Malmström 2007), combined manual treatment, exercise, modalities, and medication (Bracher et al. 2000), and SNAGs (Reid et al. 2008) have all been shown to treat CD.

If you believe your patient to truly have cervicogenic dizziness come up with the best impairment based evaluation you can do and treat what you find.

Steve