Should you use Cervical Distraction to diagnose Cervicogenic Dizziness?

Cervical Distraction Test, or also known as Foraminal Distraction Test or Neck Distraction Test, is a common orthopedic test. It has historically been utilized and studied to determine nerve root compression indicating a diagnosis of cervical radiculopathy, especially in the prevalent lower cervical spine.

The diagnostic utility is fair to poor (less than a coin flip) in regards to screening, but has promising value to be a specific test. Additionally, the test is 1 of 5 variables that, if positive, indicate that a patient would benefit from cervical traction through a preliminary CPR back in 2009. The latter makes common sense and for most of you reading, it has probably been preached to you in your graduate studies. Nevertheless, a positive test is not an encouraging screen to help your clinical reasoning to rule out nerve root compression, but can aid later in your examination to rule it in.

Cervicogenic Dizziness (CGD) or also known as Cervical Vertigo, is caused by an aberrant or erroneous somatosensory afferent input from the cervical spine into the central nervous system centers causing vague disorientation and dysfunction in postural control. The particular origin of altered somatosensory dysfunction could arise from multiple structures but typically stems from the upper cervical spine proprioceptive and muscle spindle sensitivity.

THE QUESTION REMAINS, SHOULD YOU USE CERVICAL DISTRACTION TO DIAGNOSE CERVICOGENIC DIZZINESS?

Considering it is well understood that the dysfunction is in the upper cervical spine associated with Cervicogenic Dizziness, the reader can question why a diagnostic test, typically associated with the lowercervical spine, is utilized as diagnostic criteria?

The use of Cervical Distraction in the diagnostic criteria for the diagnosis of Cervicogenic Dizziness, to my knowledge, has been declared in two reports from the literature.

The first comes from Rob Landel, who can be considered one of the leaders in the education of CGD, describes a case report at the WCPT in 2015. Clinical findings suggested there was no central or peripheral vestibular involvement, CNS or cardiovascular impairment, and that vestibular migraine was unlikely. Based on previous experience with patients presenting similarly, a trial of cervical traction in sitting was attempted and proved successful, suggesting CGD. Accordingly supine manual traction was applied, with symptom resolution that lasted for 15–20 minutes. The patient was instructed in home traction using a towel tied to a doorknob, DNF and JPE exercises.

The second comes from a recent 2017 review entitled, “How to Diagnose Cervicogenic Dizziness” by Reiley et al. This is a phenomenal article by the way and I highly recommend reading. It follows along very nicely with my Optimal Sequence Algorithm (previous blog posts here, here, and here). Quoting Richard Clendaniel’s book in 2014, the authors state, “a reduction of dizziness symptoms in response to cervical traction implicates involvement of the cervical spine and is more consistent with CGD than with vestibular dysfunction. It is best to perform traction with the patient sitting in order to minimize the effect of gravity on the vestibular system”.

THE QUESTION REMAINS, SHOULD YOU USE CERVICAL DISTRACTION TO DIAGNOSE CERVICOGENIC DIZZINESS?

Within several other disciplines (chiropractic, osteopathic, surgical), it is hypothesized that the dysfunction in the upper cervical spine stems mostly from pathology in the lower cervical spine. The dysfunction is mostly described as a facet joint problem or cervical disc problem, especially degenerative in nature. From a physiotherapist’s viewpoint, this can be conjectured from a postural issue, such as forward head posture, placing the upper cervical spine in extension in relation to a more flattened, mid-cervical spine. In a nutshell, this can lead to overactivity of the superficial cervical musculature and increased tone in the upper cervical extensors.

So yes, a positive Cervical Distraction Test (abating concordant symptoms) could very well be diagnostic in the diagnosis of Cervicogenic Dizziness. However, I would be highly suspicious of this test alone, as one test is no test, and used only after excluding other causes. Outside of the above two citations, the use of this test as in inclusion criteria is absent in every other piece of literature, including the most rubust RCTs for Cervicogenic Dizziness to date. Therefore, we have to question its validity in this specific population. As a diagnosis with controversy between professions, you have to have a powerful and step-wise examination approach.

Even in a diagnostic test that is considered specific, we have to be aware of the non-specific effects of a practitioner’s hands on someone in a relieving manner as this could cause a great deal of false-positives. Asking a patient if their symptoms are better after you distract their neck (which is relieving to anyone!) can certainly make a non-mechanical cause of dizziness more comforting.

Therefore, using the Cervical Distraction Test for Cervicogenic Dizziness judiciously, alongside appropriate clinical reasoning and in the correct order in examination can assist in your final diagnosis.