Cervical vertigo can mimic symptoms of other conditions such as BPPV , central vertigo and vestibular neuritis.

Test includes –

• MRI
• SPINE  X-RAYS
• VERTEBRAL DOPPLER ULTRASOUND
• VERTEBRAL ANGIOGRAPHY

Rule out VBI

Dizziness is the most common complaint associated with vertebrobasilar insufficiency (VBI). VBI is an uncommon presenting condition but when dizziness is present before proceeding with physiotherapy management must rule out VBI by assessing for the following symptoms. The presence of one of these symptoms is enough to warrant caution and further investigation.

• 5D’s
  • Dizziness
  • Diplopia, blurred vision or transient hemianopia
  • Drop attacks (loss of power or consciousness)
  • Dysphagia (problems swallowing)
  • Dysarthria (problems speaking)
• 3 N’s
  • Nystagmus
  • Nausea or vomitting
  • Other neurological symptoms
• 5 others
  • Light headiness or fainting
  • Disorientation or anxiety
  • Disturbances in the ears – tinnitus
  • Pallor, tremors, sweating
  • Fascial paraesthesia or anaesthesia.

OBJECTIVE TESTING

Examination of the cervical region

The assessment of CD is complex, since there is no single specific and conclusive diagnostic test. No one test alone can diagnose CD, but that clinical reasoning of the findings in a cluster of tests, associated with the patient’s subjective reports and cervical musculoskeletal impairments, is most useful for differential diagnosis of CD. In the assessment it is necessary to consider the subjective examination in conjunction with findings of cervical musculoskeletal and sensorimotor dysfunction. A normal cervical examination can be performed. Any dizziness reported in the cervical assessment indicates the need for further investigation

• Vertebral Artery Test
  • The vertebral artery test is used to test the vertebral artery blood flow, searching for symptoms of vertebral artery insufficiency and disease.
  • Performance: The patient sits in front of a wall on a distance of 90cm with a laser attached on a hairband. The starting point of the laser is marked on the wall. The patient performs 1D head motions with the eyes closed and tries to reproduce his neutral head position.  
  • Measure the distance between the starting point and the point where the laser stops after the head movement. The critical distance is 7cm. This is also called the ‘joint positioning error’ (JPE). 

• Romberg Test
  • Performance: The patient stands upright with both feet together. First the test is performed with the eyes open, then with the eyes closed.
  • Assessment: Check if the patient gets dizzy or looses his equilibrium with the eyes open and/or closed. Look for deviations, direction of deviations and influence of distraction.

• Finger-pointing Test 
  • Performance: The patient sits or stands in front of the therapist. The patient has to follow with his index finger the finger of the therapist as accurately as possible without touching it.
  • Assessment: Assess the direction of overshoot and intention tremor.

• Babinski-Weil Test 
  • Performance: The patient walks 4 or 5 steps forwards and backwards with the eyes closed and both arms stretched forward at shoulder height. This is repeated a couple of times without opening the eyes in the meantime.
  • Assessment: Evaluate deviations and the direction of deviations of a straight for- and backwards walking pattern. The consecutive deviations can form a typical pattern assembling a star. Compare the width of the support base (wide vs narrow) between walking with the eyes open and closed.

• Nystagmus test with cervical rotation
  • Performance: Evaluate spontaneous nystagmus. First look at the patients eyes while the patient looks at a point in front of him at a distance of more than 2 meters. Then the presence of a spontaneous nystagmus is evaluated while the patient stares from different eye-angles, such as looking upwards or to the left.
  • Assessment: Check the presence of a nystagmus. Nystagmus is an involuntary, rhytmic, osscilatory eye movement. A spontaneous nystagmus is a reason for referral for specialistic examination, regardless of direction, frequency or speed.

• Saccadic eye movements 
  • Performance: The patient quickly changes his gaze from one point to another.
  • Assessment: Assess the presence of overshoot or undershoot of the eye movements and aberrant saccadic eye movements.

• Smooth Pursuit Test 
  • Performance: The patient keeps the head steady and tries to follow a slowly moving object with his eyes.
  • Assessment: Look for influent eye movements or saccades. Other recognisable symptoms can be provoked

• Gaze stability
  • Performance: The patient tries to keep his eyes fixed on a stable object while the head is actively moved into different directions.
  • Assessment: Evaluate the impossibility to fixate and the presence of saccadic or aberrant neck movements. Other recognisable symptoms such as dizziness, blurred vision and nausea can be provoked.

• Eye-head coordination 
  • Performance: First the patient moves his eyes towards a fixed object. While keeping his gaze fixed at the object he turns his head towards the object. This can be performed into different directions: left, right, up, down,…
  • Assessment: Check for impossibility to dissociate eye- and head movements. Other recognisable symptoms can be provoked.

• Whisper test 
  • Performance: The test can be performed while the patient is sitting or standing. Perform the test at patient’s height. The therapist sits or stands behind the patient at arm’s length. The patient covers one ear and has to repeat the combinations that are whispered by the therapist. These are six combinations of three numbers or letters. For example: 66F, G8D, 1KL.
  • Assessment: The test is aberrant if the patient cannot repeat more than four (out of six) combinations

• Vestibular Vertigo
  • Vestibular vertigo is characterised by onset is sudden that lasts minutes, hours or days, and is accompanied by vegetative manifestations and hearing symptoms. Peripheral vertigo can be differentiated from central vertigo, given that the former often has a shorter duration and it can be accompanied by hearing loss and/or tinnitus, and there are no neurological signs.

• Dix-Hallpike manoeuvre 
  • Performance: The patient takes in a long-sitting position. The head is turned 45° to one side. The therapist assists the patient quickly getting into the supine position with his head over the edge of the table in 30° of extension, maintaining the rotation. This position is maintained for at least 30 seconds. The test is repeated with the head turned to the other side. 
  • Assessment: Note whether the test is positive for rotation of the head to the right, to the left or both. Check occurance of vertigo, presence and direction of nystagmus, latention time and time before nystagmus/vertigo has disappeared. 

• Roll test

  • Performance: This test is only performed if the Dix-Hallpike is negative but there is a strong suspicion of BBPV. The patient lies supine with his head 30° flexed. The therapist assists the patient rolling quickly to one side. The head stays in 30° of flexion. This position is maintained for at least one minute. The test is repeated with rotation to the other side.

  • Assessment: Occurence of vertigo, presence and direction of nystagmus, latention time and time before the nystagmus/vertigo has disappeared.