Why all Vestibular Therapists Should Use Manual Therapy

It is well known that vestibular rehabilitation is an effective program for many patient profiles that can walk into a physical therapist office. A well-planned and adjusted program based off of symptoms is the basis behind strategies to improve Chronic Unilateral Vestibular Hypofunctions, Bilateral Vestibular Hypofunctions, mTBI and post-concussion syndrome.

Cervicogenic Dizziness, Cervical Vertigo, Neck Dizziness

It can be individualized through a tailored, progressive program to the patient for effective outcomes. Improvement is typically gradual as the system adapts and includes a home exercise program.

Classical signs and symptoms of vestibular dysfunction that would warrant vestibular rehabilitation include dizziness, vertigo, disequilibrium, nausea, and visual impairment. With the ongoing scientific research showing neurological connections via several reflexes and mismatch theories of afferent information, a healthcare provider should also consider vestibular rehabilitation for chronic neck pain.

In fact, I would bet majority of the patients whom are seeking out vestibular rehabilitation has either cervical pain and/or limitations in cervical function (i.e. altered active/passive range of motion, strength and endurance of deep cervical flexors/extensor, cervical kinesthetic sensibility, greater joint position error, pressure pain sensitivity).

Not just me making this comment, but Knapstad and colleagues in 2019 made the following conclusion in a cross-sectional study in Disability and Rehabilitation Journal:

Neck pain was equally prevalent in patients diagnosed with dizziness of vestibular and non-vestibular origin. This indicates that neck pain is a common complaint in dizzy patients regardless of diagnosis.

Additionally, Thompson-Harvey & Hain in 2019 documented that symptoms endorsed by subjects with cervical vertigo, migraine, and vestibular vertigo overlap. Therefore, neck limitations, due to pain, stiffness or even abnormal imaging findings with both local neck origin, as well as a double entity of vestibular or central origin, can manifest an exaggerated proprioceptive response and translation into subjective symptoms of dizziness, lightheadiness and imbalance.

The basis behind Cervicogenic Dizziness treatments is that the patient has dizziness originating from the cervical spine, but couldn’t it be plausible that the dizziness could be coming from another source (i.e. peripheral) but compensatory strategies over time make it appropriate and quite reasonable to also address changes in the cervical spine due to altered head on neck orientation?

The basis behind mechanisms of manual therapy has been changed away from just local, biomechanical changes to the tissues to a more complex peripheral and central mechanisms. Majority of the clinical effects are now known to be neurophysiological in nature. Therefore, considering these patients have a head on neck disorientation that does warrant vestibular rehabilitation, could we get faster results, more buy in and ease of any nocioception that may hinder clinical outcomes.

I like this quote from a 2018 study by Daniel García-Pérez-Juana, et al :

It is plausible that manual therapies can immediately enhance proprioception and may be a reasonable treatment approach to prepare a patient for exercise interventions.

The study quoted above examined Cervicocephalic Kiniesthetic Sensibility, Widespread Pressure Pain Sensitivity and Neck pain following spinal manipulation to the cervical spine. Even if you do not believe in spinal manipulation or do not feel comfortable performing it on patients, it is wise to seek out some type of manual therapies that focus on high content from the muscle spindle and proprioceptive areas that is time-efficient, straightforward and effective.

This is why our Physio Blend incorporates your past knowledge and skill set with manual therapies without providing such “systems” as if you would feel like you need to learn before application. Our Physio Blend for Cervicogenic Dizziness includes both joint and soft tissue/muscle manual intervention. And trust us, treating the neck is MUCH more than prescribing ROM and upper trapezius stretching.

So even if your patient is not having neck pain (so therefore, may not actually be able to be classified as Cervicogenic Dizziness), a vestibular/neuro therapist should consider manual therapies to the cervical spine due to its effects on proprioception, pain and cervical kinaesthetic sense.

I’ll end this post with another quote from Knapstead in 2019:

The relationship between neck pain, general and dizziness-related quality of life should make medical practitioners aware of these patients regardless of whether or not a vestibular disorder has been diagnosed.

You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course. Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.

If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

AUTHORS

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

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