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Table 2 Test descriptions

From: How to diagnose cervicogenic dizziness

Diagnosis Test Performance description Explanation
Traumatic Cervical Spine Injury Canadian
C-Spine Rule
1) Any high-risk factor present: Age ≥ 65 years OR Dangerous mechanism* of injury OR Paresthesias in extremities. If YES to any, radiography should be performed. If NO to all, continue to 2.
2) Any low risk factor that allows safe assessment of range of motion? If NO to all, radiography should be performed; if YES to any, continue to 3. Low risk factors defined as: Simple rear-end motor vehicle collision† OR Sitting position in emergency department OR Ambulatory at any time OR Delayed (not immediate) onset of neck pain OR Absence of midline cervical spine tenderness.
3) Able to actively rotate neck 45° left and right? If unable, radiography should be performed.
*Fall from elevation ≥0.9 m (3 ft)/five stairs, axial load to head, motor vehicle collision at high speed (>100 km/h), rollover, ejection, motorized recreational vehicles, bicycle struck, or bicycle collision.
†Excludes: pushed into oncoming traffic, hit by bus or large truck, rollover, and hit by high speed vehicle.
Canadian C-Spine Rule is a tool to help clinicians decide if radiography should be utilized in patients following traumatic injury. It is only applicable to patients who are alert (Glasgow Coma Scale score ≥ 15) and in stable condition following trauma where cervical spine injury is a concern. Canadian C-Spine Rule is not applicable in non-trauma cases, for patients with age < 16 years, during pregnancy, or for patients with unstable vital signs, acute paralysis, known vertebral disease, or previous history of cervical spine surgery.
Upper Cervical Instability Alar Ligament Test [45] 1) Patient assumes sitting or supine position with head slightly flexed to engage the Alar ligament. The clinician assesses the patient’s resting symptoms.
2) The clinician firmly stabilizes the spinous process of C2 using a pincer grasp.
3) Either lateral flexion or rotation is passively performed by the clinician (both are performed independently of each other, in either order). While performing these passive movements, the examiner attempts to feel movement of C2.
4) A positive test is defined by lack of palpable movement of the C2 spinous process during lateral flexion or rotation.
The purpose of this test is to examine the integrity of the alar ligaments following traumatic injury involving the cervical spine. If the alar ligaments are intact, lateral flexion or rotation of the head should result in palpable contralateral movement of the C2 spinous process. Caution is of utmost importance when administering this test.
Upper Cervical Instability Sharp Purser Test [39, 45] 1) The patient assumes a sitting position with their head slightly flexed. The clinician assesses the patient’s resting symptoms.
2) The clinician stands to one side of the patient and stabilizes the C2 spinous process using a pincer grasp.
3) The clinician uses the opposite hand to gently apply an anterior to posterior translation force on the patient’s forehead.
4) A positive test is defined by symptom reproduction during forward flexion, decrease in symptoms during posterior translation, or excessive displacement (>4 mm) during posterior translation.
This test assesses the integrity of the transverse ligament that maintains the position of the odontoid process relative to C1. If the transverse ligament is torn, C1 will translate forward on C2 during flexion, indicating atlantoaxial subluxation. Atlantoaxial subluxation is the most common cervical spine complication of rheumatoid arthritis. Spinal cord compression secondary to atlantoaxial subluxation can result in severe neurological damage, including quadriplegia and fatality. Extreme caution should be used when administering this test.
Cervical Facet Joint Dysfunction Manual Spinal Examination [30] Patient positioned in prone with neutral cervical spine. Clinician applies posterior to anterior directed force to the articular pillars of the cervical spine bilaterally, one joint at a time. In a study by Schneider, et al., a positive test was defined as patient report of ≥3/10 increase in concordant local or referred pain intensity when clinician rated resistance to motion as ‘moderate’ to ‘marked’. Cervical facet joint capsules contain several sensory receptors including free nerve endings, mechanoreceptors, A-delta and C-fibers, making the joints nociceptive and sensitive to pressure and mechanical changes.
Cervical Facet Joint Mediated Pain Palpation for Segmental Tenderness [30] Patient positioned in prone. Clinician palpates deep segmental muscles overlying cervical spine facet joints bilaterally. Schneider, et al. defined a positive test as patient report of ≥3/10 increase in concordant local or referred pain intensity rating. Segmental muscles overlying painful facet joints often react with tenderness and spasm. Cervical facet joints and the muscles overlying them are innervated by the medial branch of the dorsal rami.
Cervical Arterial Dysfunction CAD Testing [22, 46] CAD testing should include the following sequential tests:
1) While seated, the patient performs end range active cervical rotation in both directions.
2) While seated, the patient performs active end range combined cervical extension and rotation in both directions
3) With patient supine, the clinician brings the patient into passive end range cervical rotation in both directions.
4) With patient supine, the clinician brings the patient into passive end range combined cervical extension and rotation in both directions.
5) Any position that the patient reports as provocative.
All positions should be held for a minimum of 10 s, unless symptoms are provoked sooner. After each sustained position, the patient should return to neutral cervical spine position for at least 10 s to allow for any latent response to emerge. Throughout CAD testing, the clinician should observe the patient’s eyes for nystagmus, and the patient should report any provocation of symptoms. Positive signs and symptoms include dizziness, nystagmus, diplopia, loss of consciousness, diaphoresis, dysphagia, dysarthria, nausea, numbness around the lips, or other neurological symptoms.
CAD testing involves neck rotation and extension with a stationary body, causing decreased blood flow in the vertebrobasilar arteries with rotation alone and internal carotid arteries with combined extension and rotation. CAD testing requires cervical extension and rotation passive range of motion that is within normal limits.
Vestibular Hypofunction Head Thrust Test [43] Grasp the patient’s head firmly with both hands and pitch their head forward 30° to align the horizontal semicircular canals. Instruct the patient to look at your nose. Gently move the patient’s head back and forth with intermittent high velocity, randomly timed thrusts. While performing head thrusts, observe the patient’s eyes to determine whether they are able to maintain ocular fixation on your nose or not. A failure to maintain fixation on the visual target (nose) indicates hypofunction on the side that the thrust was directed toward. A refixation saccade will be visible for patients who are unable to maintain visual fixation. This test is most valid if the thrusts are performed with random timing that does not allow anticipatory compensation.
Peripheral Vestibular Dysfunction Head Shaking Induced Nystagmus [47] Grasp the patient’s head firmly with both hands and pitch their head forward 30° to align the horizontal semicircular canals. Instruct the patient to close their eyes. Passively oscillate the patient’s head side to side 20 times at 1–2 Hz. Instruct them to open their eyes just prior to completing the 20 side to side movements. Observe for post-headshake nystagmus. The direction of the fast phase of nystagmus denotes the side of higher vestibular functioning. Therefore, the side of vestibular hypofunction is on the side contralateral to the direction of the fast phase.
Benign Paroxysmal Positional Vertigo Dix-Hallpike Test [42] The patient is initially sitting upright with legs extended. The clinician passively rotates the patient’s head 45° toward the side being tested. The clinician helps the patient to rapidly lie down on the table while keeping the head slightly extended. The clinician observes the patient’s eyes for nystagmus for at least 60 s; there can be a latency period of up to 15 s before the onset of nystagmus. The direction of the nystagmus beats will be on the same side as the involved canal. With right sided BPPV, for example, the fast phase of nystagmus will beat to the right with a slow saccade back to the left. Patients with posterior canal BPPV will have a positive Dix-Hallpike test and concomitant vertigo.
Horizontal Canalilithiasis or Cupulolithiasis Head Roll Test [48] The patient is initially positioned in supine with their neck flexed 20°. The clinician quickly rotates the patient’s head 90° to either side and observes for nystagmus for at least 60 s. The clinician slowly returns the patient’s head to midline, maintaining neck flexion, then repeats the procedure on other side. Like the Dix- Hallpike, the nystagmus will beat towards the affected ear with a slow saccade moving in the opposite direction following the fast beat of nystagmus. When the head is rolled toward the affected ear, the nystagmus beats will be in a geotropic (toward the ground) manner. If the head is maintained in this position, a burst of fast beating nystagmus will occur in an ageotropic (away from the ground) fashion. When the head is rolled away from the affected ear, the nystagmus beats will be less intense and in the geotropic fashion.
Vestibular Dysfunction, Cervicogenic Dizziness Head-Neck Differentiation Test [26,27,28] The patient begins seated on a swivel chair. The clinician rotates the chair both while the stabilizing patient’s head and the patient reports any provocation of dizziness. The clinician then rotates the chair without stabilizing the patient’s head and the patient again reports any provocation of dizziness. Provocation of dizziness with trunk rotation under a stabilized head implicates the cervical spine, whereas dizziness with head and trunk rotation together (en bloc rotation) indicates a vestibular component to the patient’s symptoms. If symptoms are provoked in both scenarios, it is likely that CGD and vestibular dysfunction are comorbid. Dizziness of vertebral origin should be ruled out prior to administration of the Head-Neck Differentiation Test.
Cervicogenic Dizziness Cervical Neck Torsion Test [14] The patient begins seated on a swivel chair and turns their trunk 90° to the either the right or left, holding for 30 s, then returns their trunk to center. The patient then repeats the same process in the opposite direction. Each position, including the center positions, is maintained for 30 s. Throughout the test, the head is stabilized by the clinician and therefore motionless. The clinician also must continuously observe for nystagmus. Considered positive if nystagmus (excluding spontaneous nystagmus) of more than 2° per second is observed in any of the four positions (left trunk rotation, neutral rotation, right trunk rotation, neutral rotation).
Cervicogenic Dizziness, Whiplash Associated Disorder Smooth Pursuit Neck Torsion Test (SPNT) [34, 49] Surface electrodes are placed on the subject’s skin just lateral to the eyes bilaterally to record the corneo-retinal potential. The subject begins seated with their cervical spine in neutral position. The subject watches a visual target (LED or laser light) that moves through a 40° arc at a frequency of 0.2 Hz with a peak velocity of 20° per second. The subject is instructed to keep their head still and try not to blink while following the light closely with their eyes. The examiner gently holds the subject’s head in place. This process is then repeated with the subject’s body rotated 45° to one side with the head remaining in the same position to create cervical torsion. If 45° of trunk rotation causes discomfort, the angle can be decreased to symptom free range (minimum of 30°). The examiner gently holds the subject’s head and trunk in the position. The test is performed to the left and right sides. The mean gain (i.e. the ratio between eye velocity and target velocity) is calculated in all three positions. There is a lack of consensus in the description of proper performance methodology of the SPNT. The methods described are based on the initial study of the SPNT performed by Tjell and Rosenhall in 1998. The SPNT is a test of smooth pursuit eye movement with cervical neck torsion. The SPNT is the average value of the smooth pursuit in both the right and left trunk-rotation positions. The difference between the smooth pursuit and the smooth pursuit with neck torsion values is called the smooth pursuit neck torsion difference. The larger the difference between smooth pursuit with neck torsion and smooth pursuit in neutral, the more likely the patient is suffering from a whiplash associated disorder. The utility of the SPNT as a diagnostic tool for differentiating CGD from WAD has been studied in controlled laboratory trials, with mixed results, but has not yet been studied in a clinical setting.
Cervicocephalic Proprioception and Neck Reposition Sense Cervical Relocation Test [32] The patient begins seated, facing a wall 90 cm away, and wearing a head-mounted laser pointer that is centered on a target on the wall. The patient keeps their eyes closed while moving their neck in a specified direction, then back to what they believe to be centered starting position. The patient verbally indicates when they believe they are back to center. The patient repeats this process for right rotation, left rotation, flexion, and extension (in no particular order). The mean distance from the actual center to the subjective center is used to calculate the joint position error (JPE) for each movement. An error of 4.5° is the cutoff point suggesting a failure of head and neck relocalization precision.