snags and cervical dizziness: fear no more

5/13/2009

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SNAGS AND CERVICAL DIZZINESS: FEAR NO MORE!

Professor Darren A. Rivett, BAppSc(Phty), MAppSc(ManipPhty), PhDHead, School of Health Sciences

2 May 2009

Cervicogenic dizziness: does it exist and can we treat it?

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International Mulligan Concept Conference | www.newcastle.edu.au

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Manipulative evolution?

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(Hing et al 2003)

(Palmer 1920)

6Empirical evidence

• Meta-analyses and systematic reviews indicate benefits of manipulation for:

– Acute/sub-acute/chronic mechanical neck pain

– Cervicogenic headache

– Sub-acute whiplash

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Sub acute whiplash

– Thoracic spine pain

– Acute/sub-acute/chronic mechanical low back pain

• Probably not superior to mobilisation

• Better and longer-term effect when combined with exercise

• Further research is needed(ACC 2003; APA 1999, 2002; Gross et al 2004; MAA 2001;

NHMRC 2003; van Tulder et al 2006)

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7Types of HVT complications

Stroke (VA, occasionally ICA)Severe or ↑ neck, arm, head painRadiculopathy

Transient symptoms / signs of VBICervical disc herniation Myelopathy

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Musculoskeletal strain/sprainVertebral dislocation Venous sinus & tracheal ruptureCranial nerve lesions

Vertebral fracture Anterior spinal artery occlusionCardiac arrestDiaphragmatic paralysis

(Rivett 2004)

8Complications by region

Cervical Thoracic Lumbar___________________________________________ 14 stroke (12 VA) 3 myelopathy 3 radiculopathy7 radiculopathy 1 fracture 3 disc prolapse

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p y p p3 disc prolapse 1 disc prolapse 3 disc pr + rad2 increased pain 1 increased pain 1 unknown

___________________________________________Total = 26 Total = 6 Total = 10

(Rivett & Milburn 1997)

9Vertebral artery

• Intimately related to the cervical vertebrae

• Supplies brainstem, cerebellum, some of the cerebral cortex,

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,spinal cord

• Forms a fixed loop between the axis and atlas

• Anatomical anomalies common

(Freed et al 1998)

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11Effect of rotation on VA

• VA may ‘kink’ with contralateral rotation, notably at C1-C2• May result in VBI, especially if opposite VA flow is inadequate• Are flow changes predictive of manipulative stroke? Likely indicate

biomechanical stress of the artery (Haynes 2000)

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(Dvorák & Dvorák 1990)

12The HVT debate

• Commonly used for neck dysfunction & headache

• Manipulative complications

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described since 1907• Limited evidence for

efficacy (Gross et al 2002, Hurwitz et al 1996, NHMRC 2003)

• Safer, equally effective alternatives?

• Is screening possible?

(Rivett 2004)

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13Risk of vertebrobasilar stroke

• Medicine <1 per 150,450 manipulations (Dvorák et al 1993)

Unknown, but rough estimates:

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• Chiropractic 1.3 per 100,000 patients < 45 years (Rothwell et al 2001)

• Physiotherapy 1 per 163,371 manipulations (Rivett & Milburn 1997,Rivett & Reid 1998)

Most common pathology is intimal dissection

14Relative risk

Put in context…

• Stroke 1 per 163,371 physiotherapy manipulations (Rivett & Milburn 1997,Rivett & Reid 1998)

• Die in MVA this year 1 in 6,000

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y ,

• Die by homicide this year 1 in 10,000

• Die of tuberculosis this year 1 in 200,000

15Hazardous practices

• Multiple manipulations in any one treatment session

• Repeated manipulations over a number of treatment sessions

• Manipulating without having first assessed the effect of mobilisation

• Non-specific, multi-segmental techniques

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• Thrusting through large ranges of physiological movement

• Techniques involving upper cervical spine rotation

• Manipulating at end-range cervical spine rotation or extension

• Techniques involving a traction component

• Applying excessive force in the thrust component

(Rivett 2004)

16Pre-manipulative screening

• Assess for VBI symptoms / signs and adequacy of collateral circulation (Cagnie et al 2006)

• Tests involve sustained end-range rotation extension

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rotation, extension, rotation/extension (Maitland 1986, Rivett 2004)

• APA ‘Protocol for Premanipulative Testing of the Cervical Spine’ (1988)

• Other countries followed eg UK, South Africa (Barker et al 2000)

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anxiety dysphagia peri-oral dysaesthesia ataxia hearing disturbances photophobia

blackouts hemianaesthesia pupillary changes

changes in sweating hemiparesis sensory changes extremities, face or head (numbness)

VBI test positive responses

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clumsiness incoordination syncope

diplopia light headedness tinnitus

disorientation loss of consciousness tremors

dizziness or vertigo malaise unsteadiness

drop attacks nausea or vomiting visual disturbances

dysarthria nystagmus weakness

(Kerry & Taylor 2006, Rivett 2004)

18Validity of VBI tests

• Increasing ultrasound researchinto VA flow during provocative tests

• Validity of tests in patients questioned:• false positives (specific?)

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• false negatives (sensitive?)• in vivo studies inconclusive

(Gross et al 2004, Rivett et al 2000, Thiel & Rix 2005)

• “The controversial findings of the blood flow studies highlight the necessity for caution and jurisdiction in interpreting all pre-treatment test results” (Mitchell 2007)

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19VA ultrasound researchFlow changes

• Arnetoli et al 1989• Danek 1989• Stevens 1991• Refshauge 1994• Haynes 1996• Li et al 1999• Rivett et al 1999

No flow changes• Weingart & Bischoff 1992• Simon et al 1994• Thiel et al 1994• Cote et al 1996• Petersen et al 1996• Licht et al 1998 • Licht et al 1999

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Rivett et al 1999• Mitchell 2003• Arnold et al 2004 • Mitchell et al 2004

Licht et al 1999 • Haynes & Milne 2000 • Licht et al 2000• Zaina et al 2003

(Magarey et al 2004, Thomas, Rivett et al 2009)

20Symptoms of dissection

• Clinicians should recognise early clinical features of cranio-cervical arterial dissection

• Early symptoms of dissection: sudden, severe, sharp pain

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sudden, severe, sharp painacute ipsilateral postero-superior neck and occipital regionoccipital headache VA; temporal headache ICA (Thomas, Rivett et al)

no past history of similar pain (www.mayoclinic.com)

(Dittrich et al 2007, Haldeman et al 2002, Krespi et al 2002,Norris et al 2000, Thiel & Rix 2005)

21Continuous-wave Doppler velocimeter

• Haynes showed excellent validity and reliability (Haynes 2000)

• Velocimeter identified

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about one third of subjects with abnormal flow findings (Thomas, Rivett et al 2009)

• These individuals would not have been identified with provocative tests

22Dissection risk factors

Some evidence for:

• Mechanical stress / trauma of neck eg MVA, HVT • Recent infection • Hereditary subclinical connective tissue disorders?

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y• Atherosclerotic plaques?• Migraine?• Smoking?

(Dittrich et al 2007, Inamasu & Guiot 2005, Maroon et al 2007, Martin et al 2006, Rubinstein et al 2005, Smith et al 2003)

23Hunter New England Study

Stage 1 Retrospective review of medical records 2002-9

Craniocervical arterial dissection cases aged ≤55 years- vertebral artery- basilar artery

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- internal carotid artery

Inspected for- risk factors reported in the literature- presenting signs and symptoms- radiological evidence of dissection

(Thomas, Rivett et al)



Compared to other young stroke cases (controls)- 42 dissection cases, 42 controls - 25 (60%) male dissections, 21 (50%) male controls

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- mean (SD) age 37.7 (10.5) years dissections, 42.0 (7.5) controls

Dissected arteries- 23 (55%) vertebral artery- 1 (2%) basilar artery- 18 (43%) internal carotid artery


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Risk factors- mild mechanical trauma

Factor Casesn=42

Controlsn=42

Hypertension 9(21%) 20(48%)

Smoking 14(33%) 25(60%)

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mild mechanical traumahead/neck within preceding 2 weeks: 26 (62%) dissections, 3 (7%) controls- cervical spine manual therapy within preceding 2 weeks: 11 (26%) dissections, 1 (2%) control

High cholesterol 8(19%) 19(45%)

Recent infection 10(24%) 4(10%)

Family history 4(10%) 5(12%)

Vessel abnormalities

16(38%) 5(12%)




Headache- VBA dissection cases 21/24

Symptom VBAn=21

ICAn=14

Frontal headache

7(33%) 3(21%)

Temporal headache

1(5%) 7(50%)

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VBA dissection cases 21/24 (88%)- ICA dissection cases 14/18 (78%)

Occipital headache

15(71%) 3(21%)

Neck pain 15(71%) 8(57%)

Unsteadiness /ataxia

17(81%) 7(50%)

Dizziness 13(62%) 1(7%)


27Differentiate dizziness?

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(Rivett 2004)

28APA cervical spine screening guidelines

50% of Member Organisations of IFOMT use the Australian guidelines

(Rivett & Carlesso 2008)

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Australian Physiotherapy Association

Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders

© APA February 2006

(Rivett et al 2006)

29APA Clinical Guidelines

Key new features in the history:

• Greater emphasis on clinical reasoning

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• Enquiry as to whether neck pain or headache is suggestive of a dissecting VA

• Further information on differentiation of VBI from vestibular and other disorders

30APA Clinical Guidelines

Key new features in the physical examination:

• Less reliant on physical testing• Standard testing includes any nominated provocative

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position/movement and sustained end-range rotation (need stronger evidence before discarding tests entirely [Gross et al 2004])

• Testing only undertaken when possible VA symptoms in the history are absent or vague

• Simulated manipulation position should also be tested if manipulation proposed for Rx (Arnold et al 2004, Cagnie et al 2005)

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32Vestibular system vertigo

BPPV VBI

Position/movement Specific head movement in relation to gravity, +ve H ll ik

Sustained neck posture

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Hallpike manoeuvreNystagmus Torsional, decreases Vertical, continues

Fatiguability Intensity decreases Intensity increases

Signs/symptoms Rotatory vertigo, disequilibrium

5 Ds, hemiparesis, visual disturbances

(Magarey et al 2004)

33Definition of cervicogenic dizziness

Dizziness: • described as imbalance or unsteadiness (not

rotatory vertigo) AND

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• related to either movements or positions of the cervical spine, or occurring with a stiff or painful neck

Dysfunction in the upper cervical spine disturbing normal afferent input from articular

mechanoreceptors / proprioceptors(Reid & Rivett 2005)

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Proprioceptors of the cervical

joints and muscles

Inputs to vestibular nuclei

Inputs to vestibular nuclei that maintain balance

Experimental studies and neuroanatomy suggestplausible biological mechanism(De Jong et al 1977 Wyke 1979)

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Vestibular Nuclei

Vestibular system

Visual system(Cronin 1997, Furman & Whitney 2000)

(De Jong et al 1977, Wyke 1979)

35Incidence of dizziness in whiplash

•20-58% (Wrisley et al 2000)

•40-80% (Oostendorp et al 1999)

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40-80% (Oostendorp et al 1999)

•80-90% (Heikkila et al 2000, Hinoki 1985, Humphries et al 2002)

36Cervicogenic dizziness: associated symptoms

• Neck pain

• Neck stiffness

• Headache

• Unsteadiness of gait

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• Unsteadiness of gait

• Visual disturbances

• Numbness and paraesthesia

• Hyperalgesia

• Disturbances of concentration

Similar to VA pathology(Wisley et al 2000)

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37SUSTAINEDNATURAL

APOPHYSEALGLIDES

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GLIDES

38Description

• Mobilisation With Movement (MWM)• Generally combination of two actions:

- sustained passive accessory movement (ie mobilisation)WITH

- repeated active physiological movement

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repeated active physiological movement• ‘SNAG’ (Sustained Natural Apophyseal Glide) used in spine• Symptom-free in application

If normal gliding movement of the cervical joints can be restored using SNAGs, normal afferent input may be restored

and cervicogenic dizziness reduced(Reid & Rivett 2005)

39Aussie SNAG

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40Aussie SNAG?

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41Other dizziness differentiation tests

• Vestibular: head held still and move body

• Cervicogenic dizziness: identification by Mulligan

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y gdizziness SNAG? (Rivett 2004)

• All patients had elimination of dizziness with active movement during SNAG procedure (Reid, Rivett et al 2008)

(Maitland 1986)

42Cervicogenic dizziness exists

Reid, S.A. and Rivett, D.A. Manual therapy treatment of cervicogenic dizziness: A systematic review. Manual Therapy 10: 4-13 (2005)

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Reid, S.A., Rivett, D.A., Katekar, M.G. and Callister, R. Sustained natural apophyseal glides (SNAGs) are an effective treatment for cervicogenic dizziness. Manual Therapy 13: 357-366 (2008)

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43SNAGS and the VA

• With neck extension dizziness: - posteroanterior pressure on C2 spinous process unlikely to

significantly affect VAsPOSITIVE RESPONSE SUGGESTS CERVICOGENIC DIZZINESS

• With neck rotation dizziness: t t i i il t l C1 t

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- posteroanterior pressure on ipsilateral C1 transverse process would likely reduce relative stress of the VA

POSITIVE RESPONSE SUGGESTS CERVICOGENIC DIZZINESS OR VBI

• With neck rotation dizziness:- posteroanterior pressure on contralateral C1 transverse process

would likely increase stress of the VA, particularly the contralateralPOSITIVE RESPONSE SUGGESTS CERVICOGENIC DIZZINESS

44Fear dizziness no more!

• ‘Stay the hand’ and not treat the neck?

• Use different testing /screening procedures

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procedures

• SNAGs provide a means to immediately demonstrate the presence of cervicogenic dizziness and to enable the patient to be safely treated

(Rivett 2006)

QUESTIONS?

International Mulligan Concept Conference2 May 2009

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snags and cervical dizziness: fear no more

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