Cervicogenic Dizziness Assessment 101

Cervicogenic dizziness (sometimes called cervical vertigo) is a condition where dysfunction in the cervical spine leads to symptoms such as neck pain, dizziness, nausea, and even blurred vision. In this blog we’ll cover the assessment of proprioceptive cervicogenic dizziness, where abnormal cervical afferent input leads to such symptoms. Note, other pathologies like vertebrobasilar insufficiency or vestibular system dysfunction can cause similar symptoms, so part of your assessment should include screening for these pathologies.

If you’d like to see how a world-leading expert assessess cervicogenic dizziness , be sure to check out Julia Treleaven’s Practical, which I’ve based this blog on. With Practicals you can see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster. Learn more HERE.

Subjective

A skillful patient interview is the first step in differentiating the cause of symptoms. The main questions to ask relate to description of symptoms, temporal patterns, and triggers.

Description of Symptoms

Typically, proprioceptive dysfunction leads to unsteadiness and lightheadedness, but not symptoms like “the room is spinning”, which likely indicates vestibular dysfunction. Other proprioception related symptoms may be nausea, light sensitivity and blurred vision. On the other hand, symptoms like vomiting, noise sensitivity, and double vision likely have other causes.

Temporal Pattern

Generally, proprioceptive dysfunction leads to symptoms that last for minutes and that wax and wane, they are not constant or very brief (i.e. seconds).

Triggers

Usually, the triggers of dizziness correlate with the concurrent neck pain that patients experience (e.g. a certain posture causing both dizziness and neck pain). Conversely, symptoms triggered by sneezing, coughing, or rolling over are likely related to non-proprioceptive causes.

Based on the subjective, we can better target our assessment and determine the need for further evaluation by another medical professional.

To see the full walkthrough of an expert subjective assessment, watch Julia’s practical here.

Objective

In the objective section, we examine the function of the shoulder, balance, coordination, range of motion, joint mobility, and cervical spine motor control.

Shoulder Function

With respect to the shoulder we check for asymmetries and aberrant movement patterns of the scapulae. Postural asymmetries, such as increased anterior rotation, may be seen on the side of symptoms. Then for movements like shoulder flexion, we examine scapular motion quality and reproduction of symptoms. Lastly, we load the shoulder assessing both motor control and symptom reproduction.

You can see how Julia assesses scapular motor control in a case of unilateral neck pain in this video from her Practical.

Balance

Balance assessment helps us both track progress and differentiate between vestibular and proprioceptive dysfunction. First, the patient will assume a narrow base of support with the eyes closed. With proprioceptive dysfunction, patients may have increased anterior-posterior sway, whereas with vestibular dysfunction they may have increased lateral sway. Next, we challenge the patient to maintain a tandem stance with the eyes closed.

For dynamic balance, we first look at walking with head rotations and nods, checking for reproduction of symptoms and their ability to walk in a straight line. To challenge the vestibular system, the patient will repeat the walk, but perform those head motions rapidly.

Coordination of the head, eyes, and neck

When assessing head, neck, and eye coordination, we look for symptom reproduction, range of motion, and the ability to perform each task.

Trunk Head coordination

The trunk head coordination test examines the patient’s ability to move the head and trunk independent of each other. The patient keeps their gaze and head facing forward as they slowly turn their trunk side to side. This test changes cervical afferent input without disturbing the vestibular system.

In this video from Julia’s Practical, she demonstrates how to perform this test:

Eye head coordination

The eye head coordination test examines the patient’s ability to move the eyes and head independent of each other. Holding a marker to the side of the patient, they will look laterally with their eyes only (no head movement), then while keeping their gaze fixed on the marker, they will turn their head towards the marker. This is repeated on the contralateral side and for flexion and extension.

Gaze stability

The gaze stability test assesses the ability to maintain the eyes on a fixed object as the head moves independently. First, we hold a marker in front of the patient. Then while maintaining their eyes fixed on the marker, the patient turns their head to the right and left. The patient should be able to achieve 45 degrees of rotation in each direction.

Here in this video from Julia’s Practical, you can see her demonstrating this test.

Smooth pursuit neck torsion

We perform the smooth pursuit neck torsion test in two steps to help us differentiate between cervical versus vestibular causes of symptoms. First, while keeping the head neutral, we move a marker to the right and left to 20 degrees in each direction, while the patient follows the marker with their eyes only (not turning the head). Then, we perform the same test, but with the patient’s trunk turned at an angle of 45 degrees. Turning the trunk at an angle rotates the cervical spine, thus changing afferent input.

This two step test can be seen in the video below from Julia’s Practical.

Sustained Torsion

The sustained torsion test is another two part test which helps us differentiate between cervical versus vestibular dysfunction. First, the therapist holds the patient’s head still and with the patient’s eyes closed, the patient turns their trunk to one side. They hold this for 30 seconds. The next step is turning the trunk and head together with the eyes closed and then holding that position for 30 seconds.

Head neck differentiation

The head neck differentiation test helps us further differentiate between cervical versus vestibular dysfunction. In this test, the therapist holds the patient’s head still and with the patient’s eyes closed, the patient swivels their trunk from side to side. Then with the patient’s eyes closed, the therapist swivels the head and trunk together side to side.

In this video from her Practical, Julia shows how to couple the sustained torsion test with the head neck differentiation test.

Cervical joint position error sense

Next, we examine cervical proprioception via the cervical joint position error sense test. In this exam, the patient has a laser pointer strapped onto their head and they center the laser onto a target. Then with their eyes closed, they rotate their head to one side and then attempt to return to the starting position. The test is repeated for flexion and extension.

Cervical movement sense

Finally, we examine cervical movement sense, where the patient uses a laser pointer strapped onto their head to follow an “X”-like shape drawn onto the wall. The ideal is to have less than 10 deviations from the line and to perform the test in less than 25 seconds.

Range of motion

When we examine cervical range of motion, we are looking at both quantity and quality. For example, in patients with deep cervical flexor weakness they may overuse the sternocleidomastoid muscles to return from extension to flexion. We also want to check how scapular position affects neck motion. For example, we can check if upwardly rotating the scapula manually improves neck range of motion.

Joint mobility

The next consideration is joint mobility assessment of the cervical spine, thoracic spine, and ribs. Here we are looking at joint stiffness, muscle spasm/guarding, and reproduction of symptoms.

Motor control

The final portion of our assessment examines motor control of the cervical flexors and extensors.

Flexor motor control

First, we have the patient perform craniocervical flexion in supine. We then check for neural mechanosensitivity by having them perform craniocervical flexion with the shoulder abducted, then with the hip flexed.

The next step is using biofeedback by placing a blood pressure cuff pumped to 20 mmHg under the patient’s neck. Then the patient performs craniocervical flexion, attempting to hit 22 mmHg. They keep performing craniocervical flexion sequentially, to hit 24, 26, 28, and finally 30 mmHg. We check for the ability to perform each step and if they compensate through superficial neck muscle activation.

Extensor motor control

In quadruped or prone on elbows we can assess cervical extensor motor control, as shown by Julia in this video from her Practical.

Wrapping up

Cervicogenic dizziness is a complex pathology with multiple causes, including the cervical proprioceptive system. After the subjective, we assess:

• Shoulder function
• Static and dynamic balance
• Coordination of the head, eyes, and neck
• Cervical spine range of motion
• Joint mobility of the cervical spine, thoracic, spine, and ribs
• Motor control

Using the framework described here, you can assess the contribution of the proprioceptive system, identify impairments to address, and determine the need for referral.

If you’d like to see exactly how Julia and other top experts assess and treat common conditions, be sure to check out Practicals HERE.