Cervicogenic dizziness: screening

Introduction

Patients with dizziness can be classified into different subgroups on the basis of different characteristics. Cervicogenic dizziness is one of the possible causes of dizziness. 1,14 It has been defined as an aspecific sensation of changed spatial orientation and disequilibrum as the consequence of a proprioceptive disorder at the level of the cervical afferents occuring with positions and movements of the neck and can be accompanied with a stiff or painlfull neck. 2,3,4 At this moment there are no diagnostic tests available to state that the dizziness has a cervicogenic origin. It is a diagnosis of exclusion where other causes of dizziness have to be excluded. The screening tool is developed to increase the probability to decide a cervicogenic origin after the patient history and clinical examination. It is indicated which findings can be reason for referral. 

Legend

Bold finding	These are findings where you have to consider referral to specialistic care because of a serious underlying pathology. Think about pathologies of the central nervous system, vestibular disorders or cardiovascular problems.
(findings in italic between brackets)	These are possible pathologies where you can think about when certain findings are mentioned.
BPPV	Benign Paroxysmal Postioning Vetigo
CAD	Cervical Arterial Dysfunction
CD	Cervicogenic Dizziness
CVA	Cerebrovasculair Accident
TIA	Transient Ischemic Attack

Practical use

The tool is developed so that the patient history and clinical examination can be taken in a structured way. There is the possibility to note one or more characteristics/findings per item. When there ar no specific findings, there has nothing to be noted. Some findings are an indication of different pathologies. A cluster of symptoms give a greater probability for a certain pathology. 

Content

• General data

Fill in general data such as name, date of birth and the date of taking the tool. 

• Diagnosis on the prescription

If applicable: fill in de diagnosis written on the prescription. If present, data about medical imaging can be noted too. 

• Patient hystory

Systematically go through all items.
If no headache and/or neckpain is reported, item 3a and/or 3b don't have to be questionned. When the patient history is finished, look back at the findings and evaluate if there is a pattern pointing at a specific pathology. When presuming a serious pathology or a situation that you cannot treat as a physiotherapist, refer the patient for further examination and/or treatment. 

• Clinical examination

Look at the tests below

Otoneurologisch onderzoek

Romberg Test: 

Performance: The patient stand upright with both feet together. First the test is performed with the eyes open, second with the eyes closed.
Assessment:MCheck if the patient gets dissy or looses his equilibrum with the eyes open and closed. Look for deviations, direction of deviations and influence of distraction.

Finger-pointing test: 

Performance: The patient sits or stands in front of the therapist. He has to follow with his index finger the finger of the therapist as accurately as possible without touching it.
Assessment: Direction of overshoot, intentiontremor.

Test of Babinski Weil: 

Performance: The patient walks 4 or 5 steps forwards and backwards with the eyes closed and both arms stretched forward at shoulder height. This is repeated a couple of times without opening the eyes in the meantime.
Assessment: Deviations and direction of deviations of a straight for- and backwards walking pattern. The consequent deviations can form a pattern assembling a star. Compare the width of the support base (wide vs narrow) between walking with the eyes open and closed.

Inspection of spontaneous nystagmus: 

Performance: Evaluate central spontaneous nystagmus. First while the patient looks at a point in front of him at a distance of more than 2 meters. Then the possibility of a spontaneous nystagmus is evaluated while the patients stares starting from different eye positions, such as looking upwards or to the left.
Assessment: Control the presence of a nystagmus. Nystagmus is an involuntary, rhitmic, osscilatory eye movement. A spontaneous nystagmus is a reason for referral for specialistic examination, regardless of direction, frequencie or speed.

Saccadic eye movements: 

Performance: The patient quickly changes his gaze from one point to anothor.
Assessment: Presence of overshoot or undershoot of the eye movements and aberrant saccadic eye movements.

Smooth pursuit test: 

Performance: The patient keeps the head steady and tries to follow with his eyes an object that slowly is moved by the therapist.
Assessment:Influent eye movements or saccades. Other recognizable symptoms can be provoked.

Gaze stability:

Performance: The patient tries to keep his eyes fixed at a stable object while the head is actively moved into different directions.
Assessment: Impbossibibility to fixate, saccadic or aberrent neck movements. Other recognizable symptoms such as dizziness, blurred vision and nausea can be provoked.

Eye-head coordination: 

Performance: First the patient moves his eyes towards a fixed object. While he keeps his gaze fixed at the object he turns his head towards the object. This can be performed into different directions: left, right, up, down,...
Assessment: Impossibility to dissociate eye- and headmovements. Other recognizable symptoms can be provoked.

Whisper test: 

Performance: The test can be performed while sitting or standing. Perform the thest at patient height. The therapist sits or stands behind the patient at arm's lengt. The patient covers one ear and has to repeat the combinations that are whispered by the therapist. These are six combinations of three numbers or letters. For example: D 66F, G8D, 1KL.
Assessment: The test is aberrant if the patient cannot repeat more than four (of six) combinations

Examination BPPV

Dix-Hallpike manoeuvre: 

Performance: The patient sits in long-sitting. The head is turned 45°. Then the patient is quickley get into the supine postion guided by the therapist whith is head over the edge of the tabel in 30° of extension, maintaining the rotation. This position is maintained foor at least 30 seconds. The test is repeated whith the head turned to the other side. 
Assessment: Note if the test is positive for rotation of the head to the right, to the left or both. Check occurence of vertigo, presence and direction of nystagmus, latention time and time before nystagmus/vertigo has disappeared. 

Roll test: 

Performance: This test is only performed if the Dix-Hallpike is negative but there is a strong indication of BBPV. The patient lies in supine with his head 30° flexed. The therapist assists the patient rolling quickly at one side. The head is still kept in 30° of flexion. This position is maintained for at least 1 minute. The test is repeated to the other side.
Assessment: Occurence of vertigo, presence and direction of nystagmus, latention time and time before the nystagmus/vertigo has diseppeared. 

Onderzoek cervicale regio

Inspectie:

Uitvoering: Inspectie in zit of stand
Beoordeling: Nagaan of er een afwijkende stand is zoals bijvoorbeeld lateroflexiestand of voorwaartse hoofdpositie.

Palpatie naar spierspanning: 

Uitvoering: Spieren palperen met vinger II en III met een dergelijke druk dat de vingertop wit kleurt
Beoordeling: Scoring pijnreactie 0-3:
0. geen pijn of zichtbare reactie
1. lichte gevoeligheid en geen zichtbare reactie
2. pijnlijke aanraking en zichtbare reactie
3. ernstige pijn en beduidende zichtbare reactie, jump sign

Functieonderzoek: 

Uitvoering: U kunt dit onderzoek uitvoeren met de patiënt in zit of in lig. Het functieonderzoek kan uitgevoerd worden volgens de richtlijnen van Aad van der El.
Beoordeling: Tijdens het onderzoek gaat u na of er sprake is van een functiestoornis en/of pijn en/of uitgelokte duizeligheid. In de bijbehorende tabel kunt u uw bevindingen als volgt invullen:

Functiestoornis: vul in welke beweging(en) in welke richting (links of rechts) gestoord is/zijn.
Pijn: vul in welke beweging(en) in welke richting (links/rechts) pijnlijk is/zijn.
Duizelig: vul in bij welke beweging(en) in welke richting (links/rechts) duizeligheid wordt opgewekt.
Indien er geen abnormale bevindingen zijn kan u een streep ‘/’ zetten.

Bijvoorbeeld:

Actief regionaal	Functiestoornis	Pijn	Duizeligheid
C0-3	Rot li, 3D flex li	Rot li	/

Cervicale repositiezin: 

Uitvoering: De patiënt zit op 90 cm van een muur met een laser op een haarband. Het startpunt van de laser wordt aangeduid op de muur. De patiënt voert 1D hoofdbewegingen uit met ogen gesloten en probeert de neutrale hoofdpositie zo goed mogelijk te reproduceren.
Beoordeling: Het punt waar de laser op wijst na de hoofdbeweging bevindt zich meer of minder dan 7 cm van de het neutrale punt.