Modern Cervicogenic Dizziness Rehabilitation Methods
For consistent success with vestibular rehabilitation, it is important to focus on a multi-modal therapy. Some balance and postural stability exercises using tools such as wobble discs or foam pads are tried and tested. However more modern equipment including lasers and app-guided solutions are now available, and proven to be highly effective rehabilitation methods for cervicogenic dizziness.
There are several treatment components required which, if combined correctly, are almost guaranteed to generate results for patients. They can be broken down into 3 main categories:
- Addressing altered cervical sensorimotor function
– Spinal manipulative therapy
– Joint position error (JPE) retraining
– Cervical motor control exercises (neuromuscular)
- Vestibular and Visual
– Eye-neck co-ordination exercises
– Gaze stabilization
– Vestibular rehabilitation therapy
– Oculomotor exercises (pursuit, saccades, optokinetic)
- Balance and Posture Stability
– Air disc
– Foam pads
– Eyes open/closed
PRIORITISING PATIENT GOALS
Therapy is ALWAYS based on assessment and patient goals. Since the nature of cervicogenic dizziness is a diagnosis by exclusion, we’re assuming that any other plausible cause (vestibular, vascular, systemic, etc) has been ruled out. The metabolic capacity (fatigue, level of function, lifestyle) of the patient needs to be considered, which is often referred to as “titrate therapy”.
Management of disturbed sensorimotor dysfunction needs to address the local causes of abnormal afferent (feedback) input. The main goal though remains to restore the sensory motor aspect, and there are many ways to achieve that. The following points are critical in laying a foundation for treatment success.
There is a hierarchy of steps that needs to be followed, and the first thing that precedes the other components of treatment is to get someone out of pain. If a patient is in pain, they’re not likely going to be able to move, or let you do anything.
This is especially important to consider since test results might be skewed if there’s an avoidance or a strong discomfort in movement.
The second thing is the spine needs movement. Without movement, again, it’s hard to control something if it’s not moving. Even if it’s arthritic, that’s fine, but you’ve got to get those joints moving. So use your techniques, use whatever you want to use to get those joints to articulate better and to restore some of that fluid mechanics to the stuff that goes with it as well.
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.
Altered cervical spine function
Adding on to the movement component, any altered cervical spine function needs to be addressed with the preferred tools of your choice. This can be spinal manipulation work or mobilisations, or any instrument-assisted work you might be trained in.
In terms of which method is most effective, the reality is that the evidence doesn’t really support one more than the other. Have a toolkit that’s as broad as you can, and if you feel that a mobilisation technique is better, then use it. If you think a manipulative adjustment is better, then use it.
Reasons why the use of lasers in practice is so attractive is their effectiveness in being able to help retrain someone’s proprioception. They are used to train ocular and vestibular aspects of the recovery. The tests are generally non-invasive and very simple to perform.
The patient is instructed to look at a target, turn their head, look at a different target, turn their head. The visual feedback allows the patient immediately to see how accurate or inaccurate their head movement is.
With this simple exercise alone, multiple body systems are engaged. The body should never really train one system over the other. The more integrated your therapies are, generally the better the result.
Below are a few examples of neuromuscular control therapies:
The patient is asked to put the head-mounted laser on. The laser is centered, and the patient is asked to move their trunk side to side. The good thing about having visual feedback of the laser is that the patient has a very clear understanding of where their head actually is.
Without that visual feedback, we can see people complete the test and say “No, no, I’m doing fine! No worries, it’s fine”. But their actual movement and coordination is in fact very disjointed. There’s so much disconnection between what they think they’re doing and what they’re actually doing. The laser then becomes a great way for them to realise themselves “Oh, that’s bad, I’m not doing that good!”.
- Head laser on centre target
- Actively swivel on chair keeping the laser centred
- Passively swivel on chair keeping the laser centred
- Progress with greater speed and distance of rotation
Joint Position Error Retraining
Practice relocating head from previously determined abnormal direction(s)
- Eyes open
- Eyes closed
- Different perturbed surfaces
- Cognitive tasking
Can add movements
- Out to in
- In to out
- Random targets
- Performed prone, legs straight, arms by side
- Laser light attached to the head, aimed at a target on the floor (60 cm distace)
- Subject performs low cervical extension with the cranio-cervical region maintained in a neutral position (light on target)
- Hold for 0-120 seconds whilst maintaining position of laser
- Add JPS retraining
- Add spinal extensor and scapular stabilisation exercises
Eye Movement Therapy
Eye movement therapy can include placing stationary targets at the periphery of the vision on each side equidistant apart (1). The head and torso are meant to remain stable while the eyes are moving.
A pursuit exercise involves a moving target traveling in a straight line from one edge of the periphery to the other (2).
Both components can be performed horizontally as well as vertically.
Specialised apps such as FocusBuilder offer various patterns and automate the tracking process with predefined standardised sequences.
In terms of compliance, if a patient sees what they’re doing and sees how poorly they’re doing it, and you’ve tied in that with their findings and what they’re complaining of, it’s not hard for someone to come in for care, and to follow through with your plan. These objective tests offer immediate feedback which is evident to the patient, and have shown to increase adherence to instructions and follow-ups.