By Marcello Cherchi, MD PhD
For patients
Some patients have neck pain that may cause disequilibrium. In some cases, manual physical therapy for the neck may help.
For clinicians
Practical summary
Absent any contraindications, manual physical therapy for the neck is a medically reasonable approach to the symptom of neck pain. It is also potentially applicable to cases of cervicogenic vertigo (CV).
Introduction
There has been extensive reporting on physical therapy for the neck as treatment for CV (Alqahtani and Kashoo 2020; Borg-Stein et al. 2001; Hoppes et al. 2020; Karlberg et al. 1996; Lystad et al. 2011; Reid et al. 2014; Reid and Rivett 2005; Yao et al. 2020; Yaseen et al. 2018), though, “Regarding the treatment of proprioceptive cervical vertigo, in which pain and imbalance or vertigo are the limiting symptoms, the quality of published studies in the current literature is poor” (Yacovino and Hain 2013).
Some authors suggest that a multimodal approach to treatment may be warranted, as discussed here: “A combined approach is likely to best address the perpetuation of a vicious cycle of events where secondary adaptive changes in the sensorimotor control system could lead to altered cervical muscle function and joint mechanics further altering cervical afferent input… Physical therapy interventions such as pain management, manipulative therapy, active range-of-motion exercises, and exercises to improve neuromuscular control will all be important in reducing possible causes of altered afferent cervical input and subsequent disturbances to sensorimotor control” (Kristjansson and Treleaven 2009). It may also be helpful to incorporate treatment from other disciplines, such as vision therapy.
Note that although vertigo is one of the cardinal symptoms of CV, “Vestibular physical therapy is not a substitute for physical therapy for the neck” (Hain 2015).
Whichever factor initiates the process that manifests with one of the symptoms (vertigo or neck pain) may in turn provoke the other, leading to the vicious cycle of a positive feedback loop. Patients who are dizzy from any cause tend to develop neck stiffness (Brandt and Bronstein 2001; Yacovino and Hain 2013), and neck problems causing vertigo defines CV. In other words, these phenomena may exacerbate each other; “interconnections between the cervical proprioceptors and the vestibular nuclei may contribute to a cyclic pattern, such that cervical muscle spasms contribute to dizziness and dizziness contributes to muscle spasm” (Wrisley et al. 2000).
Whether the neck symptoms are the cause or the consequence of vertigo, any treatments that reduce neck pain and normalize cervical muscle tone and joint mobility—basically any treatments that normalize cervical mechanics (Johnston et al. 2017; Williams et al. 2017)—will interrupt this positive feedback loop, thereby increasing the opportunity for recovery. This idea is reflected in Brandt’s comment that “If CV exists, appropriate management is the same as that for the cervical pain syndrome” (Brandt 1996).
Cautions and contraindications
Physical therapists are usually cautious about performing manual therapy on the neck of a patient with significant cervical vertebral disease, or with severe cervical spinal stenosis, or in the presence of neurosurgical hardware in the neck, or in a person with a history of carotid or vertebral arterial dissection.
Relevance in otoneurology
The main application of manual physical therapy for the neck in otoneurology is probably in the management of cervicogenic vertigo (CV).
Other notes
Note that manual physical therapy is not the same treatment modality as chiropractic manipulation.
References
Alqahtani M, Kashoo F (2020) Physical therapy in cervicogenic dizziness. Saudi Journal for Health Sciences 9. doi: 10.4103/sjhs.sjhs_11_20
Borg-Stein J, Rauch S, Krabak B (2001) Evaluation and Management of Cervicogenic Dizziness. Critical Reviews in Physical and Rehabilitation Medicine 13: 10. doi: 10.1615/CritRevPhysRehabilMed.v13.i2-3.70
Brandt T (1996) Cervical vertigo–reality or fiction? Audiol Neurootol 1: 187-96. doi: 10.1159/000259201
Brandt T, Bronstein AM (2001) Cervical vertigo. J Neurol Neurosurg Psychiatry 71: 8-12. doi: 10.1136/jnnp.71.1.8
Hain TC (2015) Cervicogenic causes of vertigo. Curr Opin Neurol 28: 69-73. doi: 10.1097/WCO.0000000000000161
Hoppes CW, Romanello AJ, Gaudette KE, Herron WK, McCarthy AE, McHale CJ, Bares J, Turner R, Whitney SL (2020) Physical therapy interventions for cervicogenic dizziness in a military-aged population: protocol for a systematic review. Syst Rev 9: 62. doi: 10.1186/s13643-020-01335-4
Johnston JL, Daye PM, Thomson GT (2017) Inaccurate Saccades and Enhanced Vestibulo-Ocular Reflex Suppression during Combined Eye-Head Movements in Patients with Chronic Neck Pain: Possible Implications for Cervical Vertigo. Front Neurol 8: 23. doi: 10.3389/fneur.2017.00023
Karlberg M, Magnusson M, Malmstrom EM, Melander A, Moritz U (1996) Postural and symptomatic improvement after physiotherapy in patients with dizziness of suspected cervical origin. Arch Phys Med Rehabil 77: 874-82. doi: 10.1016/s0003-9993(96)90273-7
Kristjansson E, Treleaven J (2009) Sensorimotor function and dizziness in neck pain: implications for assessment and management. J Orthop Sports Phys Ther 39: 364-77. doi: 10.2519/jospt.2009.2834
Lystad RP, Bell G, Bonnevie-Svendsen M, Carter CV (2011) Manual therapy with and without vestibular rehabilitation for cervicogenic dizziness: a systematic review. Chiropr Man Therap 19: 21. doi: 10.1186/2045-709X-19-21
Reid SA, Callister R, Katekar MG, Rivett DA (2014) Effects of cervical spine manual therapy on range of motion, head repositioning, and balance in participants with cervicogenic dizziness: a randomized controlled trial. Arch Phys Med Rehabil 95: 1603-12. doi: 10.1016/j.apmr.2014.04.009
Reid SA, Rivett DA (2005) Manual therapy treatment of cervicogenic dizziness: a systematic review. Man Ther 10: 4-13. doi: 10.1016/j.math.2004.03.006
Williams G, Sarig-Bahat H, Williams K, Tyrrell R, Treleaven J (2017) Cervical kinematics in patients with vestibular pathology vs. patients with neck pain: A pilot study. J Vestib Res 27: 137-145. doi: 10.3233/VES-170615
Wrisley DM, Sparto PJ, Whitney SL, Furman JM (2000) Cervicogenic dizziness: a review of diagnosis and treatment. J Orthop Sports Phys Ther 30: 755-66. doi: 10.2519/jospt.2000.30.12.755
Yacovino DA, Hain TC (2013) Clinical characteristics of cervicogenic-related dizziness and vertigo. Semin Neurol 33: 244-55. doi: 10.1055/s-0033-1354592
Yao M, Tang ZY, Cui XJ, Sun YL, Ye XL, Wang P, Zhong WH, Zhang RC, Li HY, Hu ZJ, Wang WM, Qiao WP, Li J, Gao Y, Shi Q, Wang YJ (2020) Shi-Style Cervical Mobilizations Versus Massage for Cervical Vertigo: A Multicenter, Randomized, Controlled Clinical Trial. J Altern Complement Med 26: 58-66. doi: 10.1089/acm.2019.0113
Yaseen K, Hendrick P, Ismail A, Felemban M, Alshehri MA (2018) The effectiveness of manual therapy in treating cervicogenic dizziness: a systematic review. J Phys Ther Sci 30: 96-102. doi: 10.1589/jpts.30.96
