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5/13/2009
1
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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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
May 13, 2009
International Mulligan Concept Conference | www.newcastle.edu.au
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
May 13, 2009
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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,
May 13, 2009
International Mulligan Concept Conference | www.newcastle.edu.au
,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)
May 13, 2009
International Mulligan Concept Conference | www.newcastle.edu.au
(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)
24Hunter New England Study
Stage 1 Retrospective review of medical records 2002-9
Compared to other young stroke cases (controls)- 42 dissection cases, 42 controls - 25 (60%) male dissections, 21 (50%) male controls
May 13, 2009
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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
(Thomas, Rivett et al)
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25Hunter New England Study
Stage 1 Retrospective review of medical records 2002-9
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%)
(Thomas, Rivett et al)
26Hunter New England Study
Stage 1 Retrospective review of medical records 2002-9
Headache- VBA dissection cases 21/24
Symptom VBAn=21
ICAn=14
Frontal headache
7(33%) 3(21%)
Temporal headache
1(5%) 7(50%)
May 13, 2009
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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%)
(Thomas, Rivett et al)
27Differentiate dizziness?
May 13, 2009
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(Rivett 2004)
28APA cervical spine screening guidelines
50% of Member Organisations of IFOMT use the Australian guidelines
(Rivett & Carlesso 2008)
May 13, 2009
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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
May 13, 2009
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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)
34
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
May 13, 2009
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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
CRICOS Provider 00109J | www.newcastle.edu.au