J Manipulative Physiol Ther. 2000 (Feb); 23 (2): 96–100 ~ FULL TEXT
Eduardo S.B. Bracher, DC, MD, Clemente I.R. Almeida, MD,
Roberta R. Almeida, MD, André C. Duprat, MD, Cheri B.B. Bracher, DC
Private practice of chiropractic,
São Paulo, Brazil
BACKGROUND: Cervical vertigo is a diagnosis commonly made at both otorhinolaryngologist and chiropractic offices. Hypothesized non-vascular mechanisms are reviewed. Therapeutic approaches have been suggested in the literature, ranging from cervical immobilization to vertebral manipulation.
OBJECTIVE: To characterize the patient population with cervical vertigo and observe therapeutic results of a treatment protocol by using distinct conservative modalities.
METHODS: Fifteen subjects with cervical vertigo were selected from patients presenting with dizziness at an otorhinolaryngology medical office. Diagnosis was based on specific criteria and results of an otoneurologic examination. All patients were submitted to a treatment protocol, including spinal manipulation, manual therapy on affected muscle groups, analgesic electrotherapy, labyrinth sedation, surface electromyography biofeedback, and an exercise program. Evolution of dizziness complaints and related musculoskeletal dysfunction was observed.
RESULTS: Musculoskeletal complaints were present in 93% of the patients, mainly cervical pain, shoulder-girdle pain, and tension-type headache. Median duration of musculoskeletal symptoms was 7.5 years, whereas the median duration of dizziness before the beginning of treatment was 52 days. Treatment duration averaged 5 sessions and 41 days. At the end of treatment, 60% of patients reported remission, 20% reported consistent improvement of vertigo. Remission of musculoskeletal symptoms was observed in 26.7% of patients, and improvement was observed in 60% of patients.
CONCLUSION: Chronic, nontraumatic, cervical and shoulder-girdle dysfunction was an important causal and perpetuating factor of cervical vertigo in the population studied, and a consistent improvement was observed with the use of a conservative treatment protocol involving multiple modalities for patients with cervical vertigo. Further controlled studies are needed to access its validity.
Vertigo is a symptom common to pathologies or dysfunction of a number of structures, such as the labyrinth, vestibular nerve, and afferent nerves from cervical structures (peripheral vertigo) or brain stem, cerebellum, and other supratentorial structures (central vertigo). Mixed vertigo occurs when both peripheral and central structures are affected, as in the cervical syndrome. Additionally, vertigo may be present because of metabolic, hematologic, endocrine, and other systemic diseases. 
The term cervical vertigo was introduced in 1955 by Ryan and Cope  and has become, after cupulolithiasis, the most commonly diagnosed cause of vertigo.  Despite its high incidence, a precise cause and appropriate diagnostic tests have not yet been established. Three mechanisms are usually suggested to explain the physiopathology of cervical vertigo: vascular compression, altered proprioceptive input, and vasomotor changes caused by irritation of the cervical sympathetic chain. [4, 5] Vertebrobasilar compression is a well-established vascular cause of cervical vertigo. Proprioceptive and sympathetic dysfunction are hypothesized causes on the basis of the experimental and clinical observation of the importance of those functions in the maintenance of proper balance. [6, 7]
Cervical vertigo arising from nonvascular mechanisms is also known as proprioceptive cervical syndrome or cervical syndrome of the autonomic nervous system. Associated symptoms include vertigo, tinnitus, hearing loss, and cervical pain. Physiopathologic mechanisms suggested include abnormal stimulation of articular capsule and muscular proprioceptors at the upper cervical spine, which conflict with labyrinth afferent information and thus generate vertigo.  This mechanism was first suggested to explain a similar condition arising from a temporomandibular joint dysfunction. 
Diagnostic criteria includes dizziness, episodic or persistent balance instability, tinnitus, and, less commonly, hearing loss associated with musculoskeletal complaints of the cervical region (ie, neck pain), restricted cervical range of motion, headache, and earache. Vertebrobasilar insufficiency presents the same symptoms of balance deficit, which may or may not be accompanied by musculoskeletal symptoms.
It is therefore clear that the association of mechanical, proprioceptive, and autonomic components causes cervical vertigo. For this reason, therapeutic procedures should address different causal factors. Treatment protocols for cervical vertigo have included the following therapeutic procedures:
(1) labyrinth sedation in the acute phase, with the use of drugs
that decrease the rate of firing of labyrinth efferent
(2) surgical treatment when necessary 
(3) correction of musculoskeletal abnormalities [11, 12] and
(4) vestibular rehabilitation exercises. 
This study evaluates a treatment protocol comprised of 6 integrated therapeutic modalities for patients with cervical vertigo. Patient selection, treatment procedures, and follow-up were carried out by a group of chiropractors and otorhinolaryngologists.
Diagnosis of cervical vertigo is suggested by a history of dizziness with cervical rotation, extension, and posture changes; cervical pain; and the presence of cervical rotational nystagmus. [21, 22] Otorhinolaryngologic and otoneurologic exams do not provide specific data for the diagnosis of cervical vertigo but are especially important to rule out the presence of other pathologies associated with vertigo. Given the subjectivity in the diagnosis of cervical vertigo, physical treatment, including manual therapy, may be considered as a therapeutic test.
Dizziness may be described by the patient in many different ways, including rotatory vertigo, instability, seasickness, lightheadedness, and others. Rotatory vertigo, reported by 80% of the patients studied, is a characteristic symptom of vestibular dysfunction, which makes it harder to differentiate between cervical vertigo and labyrinth pathology.  This is due to the fact that cervical syndrome affects balance by means of 2 different mechanisms: temporary alteration of labyrinth microcirculation caused by sympathetic dysfunction and vestibular dysfunction at the brain stem caused by abnormal afferent firing from cervical proprioceptors. 
Patients reported that cervical motion worsened the vertigo more than movements of the whole body. With cervical motion, stimulation of cervical mechanoreceptors is greater than mechanic stimulation of the labyrinth, suggesting a greater participation of cervical proprioceptors, as opposed to labyrinth afferent fibers, at the onset of vertigo. This is consistent with the fact that most of the patients studied reported onset of vertigo with movements that include cervical motion.
Differing from our casuistic, cervical vertigo is commonly described in an older population or in patients with whiplash injuries. [25, 26] In this article the median age was 41 years, and there was no history of cervical trauma accountable for the symptoms. The younger age of the patients may be explained by the fact that only one person (the older patient) had vertebrobasilar insufficiency (ie, a vascular cause of cervical vertigo), whereas the clinical history of all other patients was suggestive of proprioceptive cervical deficit. The absence of a history of trauma suggests that in the population studied nontraumatic, chronic, muculoskeletal conditions were the main cause of vertigo.
Eight percent of the subjects studied were women. The greater incidence of nontraumatic cervical pain in women found in some studies may account for the difference observed. 
There is a marked difference between the average duration of vertigo at the first consultation (36 days) and musculoskeletal symptoms (7.5 years). These data suggest that in the patients studied dizziness arises as an aggravating factor of chronic musculoskeletal dysfunction of the cervical spine and shoulder girdle. It is also interesting to notice that the treatment was more efficient for remission of vertigo (9 patients), an acute symptom, than for remission of pain (4 patients), a chronic problem. Two patients observed a clear relationship between the aggravation of pain and recurrence of vertigo and that the treatment was effective both for the reduction of pain and interruption of vertigo, suggesting a clear parallel between the intensity of cervical and shoulder dysfunction and the onset of vertigo.
Anxiety, present in 62.5% of the patients studied, is commonly observed as a consequence of the vertiginous state. However, it may also play an important role as a causal or perpetuating factor. There is a clear association between stress, increased muscle tonus, and increased sympathetic firing rate. [28, 29] Therefore anxiety may be acting by stimulating 2 of the most important factors associated with proprioceptive cervical vertigo.
All patients except one presented with musculoskeletal pain, demonstrating the importance of this symptom in the characterization of the pathology. Although 7 patients presented with primary pain at the suboccipital region, we observed that pain distribution tended to be diffuse rather than well localized, including both cervical and shoulder-girdle regions in 8 patients. These data suggest that cervical vertigo might be due to a summation of dysfunctional areas at several articular segments and muscle groups and not solely restricted to the upper cervical spine, as frequently suggested. 
A treatment protocol on the basis of distinct and concomitant therapeutic procedures is justified by the multiple anatomic structures and behavioral components usually involved in the pathophysiology of cervical vertigo. The present treatment protocol tried to address each of the components involved. Articular manipulation was intended for the restoration of normal, pain-free, joint motion. Manual therapy on muscles was aimed at reduction of pain and normalization of muscle tonus. Pharmacologic labyrinth sedation was prescribed during the acute period to reduce severity of the symptoms and help in the performance of activities of daily living. Surface electromyography biofeedback provides the patient with a means of awareness and control of muscle tension during daily life. Home exercises allow maintenance of muscle stretching and range of motion gained during treatments and enabled patients to gradually decrease their apprehension to perform cervical motion.
Complete remission or consistent improvement of vertiginous symptoms was reported by 80% of the patients studied, and there was no case of worsening of symptoms. The result suggests that the treatment protocol presented is indicated and effective for the treatment of cervical vertigo.
Chronic, nontraumatic, cervical and shoulder-girdle dysfunction appears to be an important causal and perpetuating factor of cervical vertigo in the population studied. A rate of remission or consistent improvement of 80% of the patients treated was observed in a group of 15 subjects with cervical vertigo treated with an integrated therapeutic protocol, including spinal manipulation, manual therapy for muscle dysfunction, medication, surface electromyography biofeed-back, and exercise prescription. Further controlled studies are needed to assess its validity.