The Neck Series: Part Two – Dizziness & the Neck

In this second of three Clinical Insight pieces about the neck we focus on dizziness. There are many types of causes for dizziness; here we think about that in relation to the neck.

It is known that whiplash injuries can alter sensory feedback from the muscle groups, disrupting cervical proprioception which may present as sensations of dizziness (Sung 2020).

Cervicogenic Dizziness (CGD) is a clinical syndrome without definitive tests, so differentiation from other common causes of dizziness such as vestibular and vascular can be a challenge. This is a tough call for the clinician.

Although the presence of neck pain should be associated with a hypothesis of CGD, any syndrome that causes neck pain could lead to resultant neck spasm and pain, due to compensation.

CGD does not commonly include tinnitus or hearing loss and therefore this may direct the clinician.

People with whiplash can report unsteadiness, pain and dizziness with over 50% exhibiting visual problems, and so a history of whiplash should lead the clinician to consider testing and then treating the resultant dizziness.

Three documented reflexes serve this system: the cervico-ocular (COR), vestibulo-ocular reflex (VOR) and optokinetic reflex (OKR), with the COR receiving input from muscle spindles in the cervical spine, in the deep cervical musculature and joint capsules from C1-C3 (Ischbeck et al 2016).

Tests for oculomotor function:

1. Gaze stability: patient keeps eyes focused on a point ahead while rotating the neck.

1. Smooth pursuit neck torsion test:aids in differentiating between cervical spine causes of dizziness and other causes, such as vestibular. In the test, eye movement is observed in either a forward-facing position or with the trunk in rotation. The patient must follow a line or moving red dot in a horizontal manner in neutral and 45° cervical spine rotation. The clinician closely observes the patient’s eye movements throughout both tests looking for jerky or fast movements, with reported increased effort, pain or dizziness.

Two simple starting exercises might be:

1. Ask the patient to hold two targets spread out vertically, roughly two feet apart. Keeping the head stable, the patient quickly moves the eyes up and down and  between the two targets. This exercise can be completed one eye at a time by cupping one eye with a hand then repeating with the opposite eye covered, or with both eyes together, depending on the individual.
2. The patient can hold a visual target with arm fully outstretched. Keeping target in the horizontal plane from the patient moves the target left-to-right or right-to-left, slowly back and forth maintaining focus. The patient may notice pain, nausea or dizzy sensations.

References

Ischebeck, B.K., de Vries, J., Van der Geest, J.N., Janssen, M., Van Wingerden, J.P., Kleinrensink, G.J. and Frens, M.A., 2016. Eye movements in patients with Whiplash Associated Disorders: a systematic review. BMC Musculoskeletal Disorders, 17, pp.1-11.

Sung, Y.H., 2020. Upper cervical spine dysfunction and dizziness. Journal of exercise rehabilitation, 16(5), p.385.