University of Groningen
Dizziness and neck pain
van Leeuwen, Roeland B; van der Zaag-Loonen, Hester
Published in:
Acta neurologica belgica
DOI:
10.1007/s13760-016-0694-2
IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below.
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Publication date: 2017
Link to publication in University of Groningen/UMCG research database
Citation for published version (APA):
van Leeuwen, R. B., & van der Zaag-Loonen, H. (2017). Dizziness and neck pain: a correct diagnosis is required before consulting a physiotherapist. Acta neurologica belgica, 117(1), 241-244.
https://doi.org/10.1007/s13760-016-0694-2
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O R I G I N A L A R T I C L E
Dizziness and neck pain: a correct diagnosis is required
before consulting a physiotherapist
Roeland B. van Leeuwen1•Hester van der Zaag-Loonen2
Received: 18 February 2016 / Accepted: 29 August 2016 / Published online: 6 September 2016 Ó Belgian Neurological Society 2016
Abstract Patients with dizziness often present with con-current neck complaints. Although there is no evidence that physiotherapy treatment of the neck reduces dizziness, many patients have been treated by a physiotherapist before they visit our tertiary dizziness centre. 1. How often do dizziness and neck complaints co-occur? and 2. how many patients have been treated by a physiotherapist for their neck complaints with a view to reduce the dizziness complaints? In a prospective observational study, the fol-lowing data were collected: age, gender, neck complaints, and whether or not the dizziness had been treated by physiotherapy. From 455 non-consecutive patients with dizziness, 192 (42 %) patients had concurrent neck com-plaints in addition to dizziness. Within this group, 87 (45 %) had been treated with physiotherapy to reduce the dizziness. In 81 patients (94 %) who had been treated with physiotherapy, the doctors of the dizziness centre discov-ered a cause of the dizziness that could be treated medi-cally. Neck complaints and dizziness often coincide. Treatment of the neck complaints with physiotherapy is frequently used. However, the causes of the dizziness are often vestibular (non-cervical) for which medical treatment is available. A correct diagnosis is required before con-sulting a physiotherapist.
Keywords Dizziness Vertigo Neck pain Physiotherapy
Introduction
Dizziness is a frequent complaint, for which it is difficult to make a diagnosis. In 30–40 % of the cases, general prac-titioners are unable to make a diagnosis—in a tertiary specialist centre, this was the case for 13 % of the patients [1]. From time to time, patients with dizziness present with concurrent neck complaints. As a result, there has been ongoing discussion about the relationship between these two complaints: is the dizziness caused by primary neck problems, such as arthritis, or do patients immobilise their neck, because of the dizziness with neck complaints as a result? The term ‘‘cervical vertigo’’ is defined as vertigo induced by changes of position of the neck or vertigo originating from the cervical region [2]. The diagnosis of cervical (cervicogenic) vertigo is made by many physio-therapists and manual physio-therapists, and is used by them as a basis for treatment. In general, consultants and general practitioners do not recognise this diagnosis [3]. The ideas about the pathogenesis of cervical vertigo are purely the-oretical and have never been supported by scientific evi-dence. There are no unambiguous criteria to identify the typical complaints for this diagnosis or validated tests to confirm the diagnosis. Furthermore, there are no (well-supported) scientific studies which show that treatment by a physiotherapist has an effect on dizziness [2–5]. How-ever, physiotherapy did improve the postural performance in a small group of patients with dizziness and neck pain [6].
A recent report describes head motion-induced spells in patients with acute neck pain; a type of cervical vertigo is considered [7]. The Apeldoorn Dizziness Centre (‘‘ADC’’) is a tertiary expertise centre for patients with dizziness as their main complaint. The centre has created a multidisci-plinary care process, in which patients receive a standard
& Roeland B. van Leeuwen r.b.van.leeuwen@gelre.nl
1 Department of Neurology, Apeldoorn Dizziness Centre,
Gelre Hospital Apeldoorn, Postbus 9014, 7300 DS Apeldoorn, The Netherlands
2 Department of Epidemiology, Apeldoorn Dizziness Centre,
Gelre Hospital, Apeldoorn, The Netherlands DOI 10.1007/s13760-016-0694-2
programme of additional investigations and are subse-quently seen by an ENT surgeon and neurologist in a joint consultation. The diagnosis is made by consensus. Annu-ally, 1300 new patients are seen in the centre, among which 800 patients come for a second opinion. Because we assumed that neck treatment to reduce dizziness was not effective, we started a prospective observational study with the following two primary questions: 1. how often do dizziness and neck complaints co-occur? and 2. how many patients have been treated by a physiotherapist for their neck complaints with a view to reduce the dizziness complaints? Moreover, we were interested to find out whether there was a difference in the diagnosis made by us between patients with and without neck complaints.
Methods
All patients referred to the Apeldoorn Dizziness Centre receive an extensive general questionnaire at home, including the ‘‘Nijmegen Questionnaire’’ for hyper-ventilation and the Hospital Anxiety and Depression Scale. The ‘‘Nijmegen questionnaire’’ has been vali-dated for the hyperventilation syndrome [8]. During half a day, all patients go through the following tests: vestibular testing (oculomotor testing, calorimetry, rotatory chair testing, positional manoeuvres), audiom-etry, orthostatic hypotension test, and a hyperventila-tion provocation test in the pulmonary function laboratory. If necessary, additional tests are requested, such as MRI, laboratory research, or duplex testing of the carotids/vertebralia. After these tests, patients are seen in the unit by an ENT surgeon and a neurologist at the same time. For patients who were referred to the Apeldoorn Dizziness Centre between 1-4-2014 and 1-9-2014 and who were seen by the primary author of this study in a joint consultation with the ENT surgeon, the following data were collected: age, gender, whether or not the patient came for a second opinion, neck com-plaints (before, at the same time, or after the dizziness started), and whether or not the dizziness had been treated with physiotherapy. If this was the case, the following additional details were recorded: who had referred the patient, what type of treatment had taken place (regular physiotherapy, manual therapy, chiro-practic therapy, remedial therapy, other), whether the aim of the physiotherapy of the neck was to reduce the dizziness, and whether the treatment had an effect on the neck and dizziness complaints. The following types of physiotherapy were not considered as physiotherapy of the neck: remedial therapy, manoeuvres for benign paroxysmal positional vertigo, and vestibular rehabili-tation therapy (for vestibular loss).
The diagnosis was made by the ENT surgeon and the neurologist by mutual consensus. Generally, accepted cri-teria for Meniere’s disease, BPPV, vestibular neuritis, bilateral vestibular loss, and vestibular migraine were used [9–13]. A diagnosis of recurrent vestibulopathy was made if the patient had experienced returning attacks of rota-tional vertigo of some minutes up to 24 h, which had not been provoked by changes of position and without ear symptoms [14].
Results
Out of a total of 455 non-consecutive patients with dizzi-ness (68 % female, average age 56 years, SD 16.5), 192 (42 %) patients had concurrent neck complaints in addition to dizziness. Neck complaints were more frequent among patients who had been referred for a second opinion (68 vs. 55 %, p 0.04) and among patients who were diagnosed with anxiety disorder (22 vs. 15 %, p 0.04).
Among patients with neck complaints, 87 (45 %) had been treated with physiotherapy to reduce the dizziness; in 82 of these patients (95 %), there was no improvement of the dizziness complaints after treatment of the neck pain. The diagnoses made for all patients and for the separate group treated with physiotherapy are provided in Table1. In 81 patients (94 %) who had been treated with physio-therapy, the doctors of the ADC discovered a cause of the dizziness that could be treated.
The most important collected data are shown in Table1. For two-thirds (64 %) of the patients with neck com-plaints, the pain had started at the same time as the dizzi-ness or after the dizzidizzi-ness had started. One-third already had neck complaints before the dizziness had started (36 %). The referrals to a physiotherapist had primarily been initiated by the patient (64 %), to a lesser extent by the general practitioner (26 %) or consultant (4 %). In some cases, it was not known by whom the patient had been referred (6 %). The treatment was undertaken by general physiotherapists (68 %), manual therapists (16 %), chiropractors (8 %), and others (8 %).
Discussion
Almost half (42 %) of the patients who were referred to our centre with dizziness complaints also had neck complaints. This is a high percentage. The prevalence of neck com-plaints without dizziness is internationally 14 % [15]. In 45 % of all the patients with neck pain, the neck was treated with physiotherapy to reduce the dizziness com-plaints. This group comprises 19 % of the total population. Among our patients, this rarely led to the alleviation of the
complaints. We are unaware of any other studies on the use of physiotherapy for neck complaints and dizziness.
We can only speculate about the reasons for the frequent use of physiotherapy in treating the combination of dizzi-ness and neck complaints. First of all, the majority of our patients went to a physiotherapist on their own initiative. Therefore, it is possible that no medical diagnosis for the dizziness was made and that the diagnosis of cervical vertigo was made—a broadly accepted diagnosis for physiotherapists. Moreover, it is possible that patients who were referred by a general practitioner did not have a clear diagnosis either. As a result, physiotherapists—per exclu-sionem—made the diagnosis of cervical vertigo and based their treatment on this diagnosis.
A number of comments can be made about our figures. First of all, we see those patients for whom the dizziness has not been cured by the general practitioner, physio-therapist, manual physio-therapist, or others. As a consequence, it is not surprising that the effect of this treatment among our patients was limited. Second, it was not a consecutive population—only those patients were included who were seen in the consultation by our main investigator together with an ENT surgeon. Because patients are randomly allocated to doctors in our centre, we do not expect that this has led to a relevant selection bias. Third, we do not have any details about the diagnosis which was made by the person by whom the patient had been referred. It is possible that physiotherapy was primarily used for patients for whom no diagnosis could be made. However, since the major part of the patients in our centre did receive an explanatory diagnosis for which adequate treatment was available, we state that in this group of patients, physio-therapy of the neck was often unnecessary and ineffective, and should, therefore, be reserved for those patients for whom a medical diagnosis is ruled out by specialist doctors.
Conclusion
Neck complaints and dizziness often coincide. To reduce the dizziness complaints, treatment of the neck complaints by physiotherapy is frequently used. However, the causes of the dizziness are often vestibular (non-cervical) for which medical treatment is available. More attention should be paid by general practitioners, and possibly also by physiotherapists, to make a correct diagnosis.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of interest.
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Table 1 Collected data on type of diagnosis, frequency of neck pain, and physiotherapy treatment Diagnoses (n = 455) (%) Neck pain ? (n = 192) (%) Physiotherapy ? (n = 87) (%)
Benign paroxysmal position vertigo 135 (29.7) 59 (30.7) 27 (31)
Anxiety/hyperventilation 81 (17.8) 43 (22.4) 16 (18.4)
No diagnosis 55 (12.1) 16 (8.3) 6 (6.9)
Vestibular migraine 48 (10.5) 24 (12.5) 9 (10.3)
Morbus meniere 34 (7.5) 11 (5.7) 8 (9.2)
Neuritis vestibularis and unknown peripheral disease 30 (6.6) 12 (6.3) 4 (4.6)
Various diagnoses 24 (5.3) 13 (6.8) 7 (8.1)
Recurrent vestibulopathy 22 (4.8) 9 (4.7) 5 (5.7)
Bilateral vestibular loss 15 (3.3) 4 (2.1) 4 (4.6)
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