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 of the cervical afferents occuring with positions and movements of the cervical spine and can be accompanied with a stiff or painlfull feeling at the neck. 2,3,4 At this moment there are no diagnostic tests available to state that the dizziness of the patient has a cervicogenic origin. It is a diagnosis of exclusion where other causes of dizziness have to be excluded first. The screening tool is developed to increase the probability to decide a cervicogenic origin after the patient history and clinical examination. In the tool it is indicated which findings can be reason for referral. 

Legend

Bold findings	These are findings where you have to consider referral to specialistic care because of a possiple 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	Cerebrovascular 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 tick off one or more characteristics/findings per item. When there ar no specific findings, nothing has to be ticked off. 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 docter's prescription

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

• Patient history

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 stands upright with both feet together. First the test is performed with the eyes open, thereafter with the eyes closed.
Assessment:Check if the patient gets dizzy 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. 

Examination of the cervical region

Inspection:

Performance: Inspection in sittng or standing position
Assessment:Check for an aberrant position such as lateral flexion of the head or forward head posture.

Palpation for muscle pain: 

Performance: The therapist palpates the muscles with finger II and III with a pressure where the fingertip gets white. 
Assessment: Scoring pain reaction 0-3:
0. no pain or visible reaction
1. light tenderness and no visible reaction
2. painfull touch and visible reaction 
3. serious pain and significant visible reaction, jump sign

Functional examination: 

Performance: The test is performed with the patient lying or sitting. The functional examination can be performed according to the guidelines of Aad van der El.
Assessment: During the examination the therapist controls functional disorders and/or pain and/or provoked dizziness. In the corresponding table the findings can be noted as follows:

Functional disorder: fill in the motion(s) and direction(s) (left/right) that are disturbed.
Pain: fill in the motion(s) and direction(s) (left/right) that are painfull.
Dizziness: fill in which motion(s) and direction(s) (left/right) provoke dizziness.
When there are no aberrant finding, a '/' kan be filled in. 

Bijvoorbeeld:

Active regional	Functional disorder	Pain	Dizziness
C0-3	Rot left, 3D flex left	Rot left	/

Cervical position sense: 

Performance: The patient sits in fornt of a wall on a distance of 90cm with a laser attached on a hairband. The starting point of the laser is marked on the wall. The patients performs 1D head motions with the eyes closed and tries to reproduce his neutral head position. .
Assessment: The point where the laser stops after the head movement is located at a distance less of more than 7cm from the neutral point.