Manual Therapy 2005 (Feb); 10 (1): 4–13
Susan A. Reid, Darren A. Rivett
Discipline of Physiotherapy,
Faculty of Health,
The University of Newcastle,
Callaghan, NSW 2308, Australia.
Dizziness is a common and often disabling disorder. In some people the cause of their dizziness is pathology or dysfunction of upper cervical vertebral segments that can be treated with manual therapy. The aim of the present study was to systematically review the literature on the manual therapy treatment of patients with cervicogenic dizziness, by identifying and evaluating both randomized controlled trials (RCTs) and non-RCTs (controlled clinical trials and non-controlled studies). Seven electronic databases were searched up to July 2003, article reference lists were screened and an expert panel elicited to obtain relevant trials. Nine studies met the inclusion criteria and key data was extracted. Two reviewers assessed the validity of the studies using the Cochrane format and found that all studies had low methodological quality. However, a consistent finding was that all studies had a positive result with significant improvement in symptoms and signs of dizziness after manual therapy treatment. Therefore, Level 3 evidence for manual therapy treatment of cervicogenic dizziness was obtained indicating it should be considered in the management of patients with this disorder provided there is evidence of improvement. This review has identified the need for further RCTs of acceptable methodological quality.
From the FULL TEXT Article:
Dizziness is a common complaint in manual therapy and practice. It can be described as light-headedness, imbalance, giddiness or unsteadiness (Oostendorp et al.,
1992a). It is a symptom of non-specific pathological
importance (Luxon, 1984). A subgroup of those with dizziness complains of vertigo which is an illusion of movement, usually rotation, whirling or spinning of the person or the environment (Froehling et al., 1994; Cronin, 1997; Aalto et al., 1998).
Dizziness and vertigo are common presenting symptoms, and were second to low back pain in frequency of
occurrence in the adult population at an American
Rehabilitation Hospital (Shumway-Cook and Horak, 1989). Dizziness accounts for eight million primary care visits to doctors in the United States each year and is the most common presenting complaint in patients over 75 years (Colledge et al., 1996). It is reported in 30% of people over 65 years and 39% of these people fall because of their dizziness (Colledge et al., 1996). It is particularly relevant to note that out of 18,263 patients presenting to The National Institute of Physical Therapy in the Netherlands for manual therapy from 1972–1992, 18% suffered from vertigo (Oostendorp et al., 1992b). In fact, 40–80% of neck traumatized patients experience vertigo, particularly following whiplash injury (Fitz-Ritson, 1991; Oostendorp et al., 1999; Wrisley et al., 2000).
The frequency of dizziness can vary from a rare episode to a constant sensation. There are many symptoms of varying severity reported by patients with dizziness. These symptoms can lead to emotional problems, disorientation, depression, anxiety, a fear of open spaces, an inability to perform activities of daily
living, employment difficulties, early retirement and family problems (Yardley et al., 1992).
There are a number of different causes of dizziness
including those arising from disturbances of the ear,
nose and throat (ENT), central nervous system (CNS),
cardiovascular system and benign positional paroxysmal
vertigo (BPPV). Although diagnosis of the disorder can
sometimes be difficult and require specialist facilities,
these problems can often be successfully treated.
However, in addition to these problems, a group of
patients remains and it is suspected that the cause of
their problem is a disorder of the cervical spine, known
as cervicogenic dizziness.
Cervicogenic dizziness was first described in 1955 by Ryan and Cope who used the term ‘cervical vertigo’ to refer to a combination of cervical spine problems and dizziness. It is defined as vertigo induced by changes of position of the neck (Luxon, 1984) or vertigo originating from the cervical region (Oostendorp et al., 1992a). Cervicogenic vertigo or dizziness has been a contentious topic since this time.
Nevertheless, there is much evidence that cervicogenic
dizziness is a distinct disorder. Injections of local
anaesthetic into the neck muscles by De Jong et al. (1977) induced ataxia and vertigo in normal volunteers. Wyke (1979) also presented experimental and clinical evidence that altered function of the mechanoreceptors in the cervical joints leads to disequilibrium and ataxia in the older population.
In a more recent study of patients with chronic cervicobrachial pain and nerve root compression, 50% were presumed to have cervicogenic dizziness (Persson
et al., 1996). It has been suggested that it is a
malfunction or disturbance in the afferent flow of impulses from deep cervical tissues and cervical proprioceptors that causes cervicogenic dizziness (De Jong et al., 1977; Luxon, 1984; Persson et al., 1996; Cronin, 1997; Oostendorp et al., 1999; Brandt and Bronstein, 2001). Traumatic, degenerative, inflammatory or mechanical problems in the cervical spine can cause cervicogenic dizziness and unsteadiness. It has been noted that the severity of the dizziness is usually proportional to the severity of more common cervical symptoms such as pain, stiffness and numbness (Wyke, 1979; Froehling et al., 1994; Bracher et al., 2000; Furman and Whitney, 2000).
Cervical vertigo is often associated with whiplash injury. Whiplash injuries will be experienced by 0.1% of the population. The incidence of symptoms of dizziness or vertigo in whiplash patients has been reported as 20–58% by Wrisley (Wrisley et al., 2000) and 80–90% by
Hinoki and Heikkila et al. (Hinoki, 1985; Heikkila et al., 2000). Besides whiplash, people with cervical spondylosis and cervical muscle spasms can also have dizziness (Ryan and Cope, 1955). It has been suggested by Hulse
that one third of people with cervical disequilibrium
have their onset due to trauma such as whiplash, one
third have insidious onset and one third have other
causes such as manual therapy (Hulse, 1983).
It is often assumed that the management of dizziness of cervical origin should be the same as for cervical pain (Brandt and Bronstein, 2001). If one is able to reproduce the patient’s dizziness on testing active cervical spine movements, or with passive cervical joint movements, a mechanical disorder is presumed to be indicated
(Cronin, 1997). It is clinically expected that manual therapy which increases the range of movement of the neck, reduces muscle spasm, and restores mechanical gliding of the zygapophyseal joints will decrease dizziness and vertigo of suspected cervical origin (Wyke, 1979; Mulligan, 1991; Furman and Cass, 1996; Wilson, 1996). Several case studies have suggested that manual therapy to the upper cervical spine can result in a reduction of dizziness symptoms in patients with
cervicogenic dizziness (Ryan and Cope, 1955; Cote et al., 1991; Fitz-Ritson, 1991; Mulligan, 1991; Cronin, 1997; Zhou et al., 1999; Kessinger and Boneva, 2000;
Wrisley et al., 2000). Nevertheless, the role of manual therapy in the treatment of cervicogenic dizziness is far
from clear and has not been systematically reviewed in
Results from the studies examined in this systematic
review showed that there is limited evidence that manual
therapy is beneficial in the treatment of cervicogenic
Due to the lack of RCTs on this topic non-RCTs were included. It has been acknowledged that RCTs are not the only or necessarily the best means of evaluating health care, and the Cochrane Collaboration has considered changing to include other research methodologies (Newman and Jacobsen 1993; Mulrow and Oxman, 1997). However, it is acknowledged that studies which are not RCTs are usually placed low on the ‘hierarchy of evidence’ (McPherson and Lord, 2000).
The study by Heikkila et al. (2000) was included for assessment of methodological quality even though it is a single subject experimental design because there were so few clinical trials. It was found to have a control group, random allocation to groups and appropriate outcome measures. Heikkila et al. (2000) was also included in an effort to eliminate inclusion criteria bias.
Besides the lack of RCTs and the low-methodological
quality of the studies another problem was the poor
reporting of the trials which often meant it was not
possible to decide if a criterion had been met.
A qualitative analysis was performed using the levels of evidence approach as recommended by the Cochrane Collaboration Back Review Group (Van Tulder et al.,
2003a). However, there are many criteria lists for
determining levels of evidence and these have not been
standardized. Questions have been raised about the validity of the levels of evidence pooling rules. It is possible that different pooling rules could have resulted in a different level of evidence for this present study (Ferreira et al., 2002).
Studies published in languages other than English were included to exclude language bias and increase precision. However, selection bias may be present in the study as only one person (SR) selected the articles. This person conducted both the citation identification and selection phase of the review. Agreement has been found to be fair to good when two people select the studies so it is still recommended.
During the assessment of the articles the authors’ names, institution and journal names were removed. Although there was no true blinding as one of the researchers was also involved in article selection, the process followed was recommended by the Cochrane Collaboration Back Review Group (Van Tulder et al., 1997). Interestingly, blinding is a somewhat controversial issue with some researchers finding that blinding resulted in lower and more consistent scores than open assessment, while others did not find this (Van Tulder et al., 1997; Jadad et al., 1998). Due to minimal evidence it is not seen as a mandatory step in performing a systematic review.
The findings of this review are consistent with findings from indirect evidence. Mulligan recommends the use of manual therapy in the treatment of vertigo and dizziness (Mulligan, 1991, 1999). The Sustained Natural Apophyseal Glides (SNAGs) technique recommended by
Mulligan to treat this condition is now taught and practised by physiotherapists worldwide. Many other authors also suggest using manual therapy on the cervical spine to treat cervicogenic dizziness (Ryan and Cope, 1955; Wyke, 1979; Haldeman, 1980; Grieve, 1981; Odkvist and Odkvist, 1988; Fitz-Ritson, 1991; Wilson, 1996; Kessinger and Boneva, 2000; Wrisley et al., 2000; Brandt and Bronstein, 2001). Borg-Stein et al. (2001)
retrospectively reviewed outcomes of 15 patients treated in an outpatient clinic with ‘rehabilitation interventions’ for cervicogenic dizziness and found 27% reported no further dizziness, with 82% of the remaining patients reporting some improvement. Several single case studies have also been reported in which manipulation has been used successfully to treat cervicogenic vertigo (Cote et al., 1991; Cagle, 1995; Cronin, 1997).
The findings from this systematic review and from indirect evidence are further supported by the proposed neuroanatomical and neurophysiological basis for cervicogenic dizziness. It has been postulated that cervicogenic dizziness is caused by cervical spine joint dysfunction and spasm of cervical muscles (Borg-Stein et al., 2001). The cervical zygapophyseal joints are the most densely innervated of all the spinal joints (Wyke, 1979). The upper cervical articular mechanoreceptors and proprioceptors contribute to static postural sensation or the sense of balance (Wyke, 1979; Hulse, 1983). The dorsal roots of the spinal nerves of C2 and C3 synapse with the nucleus abducens in the vestibular nuclei (Borg-Stein et al., 2001). Altered Type 1 cervical
articular mechanoreceptors and proprioceptors from dysfunctional joints results in a loss of normal afferent input, which leads to aberrant information being sent to the vestibular nuclei (Wyke, 1979; Cagle, 1995). So even though the vestibular system may be normal, this may
result in vertigo, poor balance or unsteadiness (Wyke, 1979). It follows that if one can restore normal gliding movement of the zygapophyseal joints in the upper cervical spine through manual therapy, normal afferent
input will also be restored and therefore cervicogenic
This systematic review has found that there is limited
evidence at present to support the use of manual therapy
in treating cervicogenic dizziness. Insufficient clinical
research of satisfactory quality has been performed on
this topic. Further RCTs, with high-methodological
quality, are needed to clearly determine the role of
manual therapy for this disorder. Future research
should examine the efficacy of individual types of
manual therapy as well as a multimodal approach.
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