Can anyone describe an MWM for cervical origin dizziness?

[msk101]

Hi All,

I'm wondering if anyone can direct me to an accurate description of how to MWM (Mobilisation with Movement) Cx for cervicogenic dizziness/lightheadedness ...my client has had neuro r/v all clear, negative Hall-Pike's, nil VBI, negative Cx quadrants, can only get reproducible dizziness on lateral approach or AP approach right C5/6 in supine. Highly hyperalgaesic Cx musculature and anxiety (had the problem for >14months, onset post Cx Mobs with another physio), Carotid small reported blockage but clinically insignificant (on doppler), bp is stable. Gait affected with left hand drift, full brain and cerebellar CT showed no probs, cranial nerves all intact on testing. Client has been sent to me as "last resort", nil response to gapping rotation approach to L side mobs and I am now thinking I'd like to MWM the Cx as it's a gentle approach but would like a couple of alternative techniques if anyone out there can be descriptive enough. - or if there's a guru out there with another idea.

Thanks for the input.

msk101

[linbin]

hi
there was an article in manual therapy journal in 2008 related to mulligen's technique for cervical dizziness .

[Physio Dace]

Can you clarify what the person describes when reporting "dizziness". How long is the duration, how quick onset, body/head positions to agg/ease etc. Is it true-vertigo (rotational spinning of room or person) or non-vertigo dizziness (light headed, unsteady etc) ? If its true vertigo then its unlikely to be cervical in origin. Are there any other symptoms present e.g. tinnitus/HA/nystagmus etc?.

C5-6 seems a little low for reproduction of classical articular cervicogenic symptoms and an accurate upper Cs quad should be positive if cervical in origin.

[neuromuscular]

Dear msk101:

Your case is interesting and I will be interested in the replies you obtain.

With all indications as negative, you have been thorough.

I once had a patient where the muscles attaching to the mastoid process were in excess tonus and the person had dizziness and conditions where nothing made sense. When I treated the digastric, some of the symptons abated. The other muscles attaching to the mastoid may have been a factor also as all were treated, but the digastric made the most difference. I cannot explain it, but it worked.

Hope that this is helpful.

Best regards,

Neuromuscular.

[msk101]

HI all,
Thanks for the input so far. Dizziness is described as lightheadedness, not true vertigo. This is a constant thing with no discernable aggs/eases although she does tend to lie-sit slowly just habitually now since this has been going on for 14 months. Nil VBI signs (no nystagmus, or nausea, nil loss of facial control, nil auditory symptoms etc). Client is very unsteady on her feet and tends to wall-walk or furniture prop but does not state that the room is spinning or rotational at all.

In my last treatment I worked primarily on right side (sore side) scalenes, lev scap and anterior cervical musculature and will review client tomorrow to see if it helped! The muscles were indeed extremely tense and painful, and I was interested in Neuromuscular's story (but only read this after the last treatment tho!) but I had to be quite gentle as client has relatively low pain threshold (or i'm just a brutal physio... which might occasionally be the case!). So it will be a slowly slowly approach (or my dear client might not come back again!) and we'll see and update later.

Cheers
msk101

[neuromuscular]

Dear msk101,

The best explanation tht I have come across on the effect of the muscles which attach to the mastoid to dizzines or vertico is that these can induce referred pain into the ear and thus upset the balance mechanism of the ear.

I must admit that my experience has been only on a few patients, so I cannot say if this is common or I just had the few select patients.

As I said, I will look forward to the other replies to this and how your own outcome is on the patient at hand.

Best regards,

Neuromuscular

[linbin]

[quote=neuromuscular;24330]Dear msk101,

The best explanation tht I have come across on the effect of the muscles which attach to the mastoid to dizzines or vertico is that these can induce referred pain into the ear and thus upset the balance mechanism of the ear.

i wonder how the muscles induce pain into ear.i would like to know the reference

[neuromuscular]

[quote=linbin;24393]

Originally Posted by neuromuscular

Dear msk101,

The best explanation tht I have come across on the effect of the muscles which attach to the mastoid to dizzines or vertico is that these can induce referred pain into the ear and thus upset the balance mechanism of the ear.

i wonder how the muscles induce pain into ear.i would like to know the reference

Dear linbin:

The best resource on this is the manuals by Janett Travell on the pain refferal patterns of the muscular systems. There are two manuals. I believe the title of the manuals is Myofascial Pain & Dysfunction: the trigger point manual.

Referred pain by muscles is by far the most overlooked problem. Visceral pain referral is used extensively by the medical practitioner, but muscular pain referral is not

Hope that this is helpful.

Best regards,

Neuromuscular

[linbin]

hi buddy
thanks a lot for the reply .i will check the book mentioned.
i agree with you that somatic referred pain are not extensively studies compared to visceral refered one

[psychophysio]

Has she been seen by a neurologist? Left arm drift is a bit weird - does she have any other cerebellar signs (abnormal Finger-nose-finger, heel-shin, rapid alt. movements, +ve Romberg)? A Ct does not give particularly good images of the brainstem and cerebellum but I suppose you would see if she had a stroke 14 months ago.

good luck!

[Fyzzio]

Hi,
after reading through all the comments, I am still wondering, what the original problem was, e.g. why did your patient had cervical mob in the first place?
To me her presentation is similar to that of a mild TBI.
She does display clear neurological symptoms, so I really am surprised, that her neurology review was all clear.
Has she had a full oculomotor and vestibular Physio assessment?
Cheers,
Fyzzio

[msk101]

HI All,

Yes, client has been seen by a neuro. I sent her back for a contrast MRI and am now hoping to hear something on that. also has had a full neuro assessment which, other than the light headedness and left drift when walking, is within normal range.

Something's not right for sure (understatement of the century).

Original Cx mob from what i can tell (i was not the treating physio) was post-shoulder surgery and prolonged sling use which resulted in Cx tension and pain. Onset of current symptoms 2 days later. presented to me 13 months later after referral from the neurologist to me.

I have seen the Travell and Simons trigger point info and have done some work on the musculature of the Cx but to no avail. other than better Cx ROM. but no symptom resolution. I am more and more thinking cerebellar infarct (perhaps the original mobs threw off a clot from the carotid artery????) and have referred back to the neuro with a long list of things i've done and want checked out more thoroughly.

oh well... you win some and lose some... fortunately the balance is generally in favour of the winning but not in this case.

Thanks to everyone for their ideas and suggestions.

Msk101

[neuromuscular]

Sorry the referred pain or paraesthesia of the work of Janett Travell et al did not work. There may be more involved. Hope that you find some other helpful info.

However, if nothing else does turn up, see if another muscle that you did not try may be a factor. It may be one that is not directly attached to the mastoid.


Best regards,

Neuromuscular.

[atcjoeyb]

I'm actually very curious about this case b/c I believe I have the same problem. I dislocated my shoulder a little over a year ago and after weeks in a sling I began to have cervical stiffness. I saw a chiro and began having severe bouts of dizziness. I stopped being adjusted and the dizziness appeared to go away, but still returns intermittently. Something just "doesn't feel right" with my neck and I sit, stand, walk, etc. very hesitantly for fear of provoking the dizziness. I was tested for vertigo, mri's (brain/shld), catscans, and everything came back negative but I still experience these bouts of dizziness. My eyes begin to hurt a little and it feels like everything gets cloudy and sometimes my neck will "pop" like a knuckle cracking causing the symptoms to diminish instantly. One time my SCM completely locked up so I try to do soft tissue on that, but I honestly feel like trigger pt. on Levator Scap. on the non-injured side (probably from compensatory tightness for the months post-injury) releases the most tension in my neck. I still think i have an instability issue, but I've seen so many doctor's and find it hard to believe they all would've missed this. I work for a physical therapy company, so it's embarassing that I cannot solve my own problem. Try working on her Levator mm. Anybody have any other ideas???

[neuromuscular]

Originally Posted by atcjoeyb

I'm actually very curious about this case b/c I believe I have the same problem. I dislocated my shoulder a little over a year ago and after weeks in a sling I began to have cervical stiffness. I saw a chiro and began having severe bouts of dizziness. I stopped being adjusted and the dizziness appeared to go away, but still returns intermittently. Something just "doesn't feel right" with my neck and I sit, stand, walk, etc. very hesitantly for fear of provoking the dizziness. I was tested for vertigo, mri's (brain/shld), catscans, and everything came back negative but I still experience these bouts of dizziness. My eyes begin to hurt a little and it feels like everything gets cloudy and sometimes my neck will "pop" like a knuckle cracking causing the symptoms to diminish instantly. One time my SCM completely locked up so I try to do soft tissue on that, but I honestly feel like trigger pt. on Levator Scap. on the non-injured side (probably from compensatory tightness for the months post-injury) releases the most tension in my neck. I still think i have an instability issue, but I've seen so many doctor's and find it hard to believe they all would've missed this. I work for a physical therapy company, so it's embarassing that I cannot solve my own problem. Try working on her Levator mm. Anybody have any other ideas???

Dear atcjoeyb,

If you have ruled out other factors, the refered pain patterns or paraesthesthesia effect of tigger points, as it is not always "pain" that is referred, can have a great effect.

The levator scap. can cause pressure to and distortion to the upper cervical bones. If the trigger pt. of the levator scap. does not correct it, then consult Janett Travell's manuals for other possibilities. The other option is a NUCCA chiropractor, but that is usually not necessary, if you can find the specific muscular distress.

Hope that this is helpful.

Best regards,,

neuromuscular.

[hanover1]

actjoey, since you had a chiropractic manipulation, that takes you into a different aetiology than msk101's patient, who aside from cervical mobilisations, had no 'trauma' to the cervical region, therefore your problems are most likely entirely different.
msk101- is it possible your patient has vestibular migraine?