L13 -14: Differential diagnosis headache and dizziness assessment

Question 1

What are the 3 epidimology for headache?

Answer 1

1. High personal and socioeconomic impacts
2. No age group is immune ‐ the young to the elderly
3. Generally predominant in females

Question 2

What are the 4 presentations of headache?

Answer 2

1. Migraine
2. TTH (Tension type headache)
3. Cervicogenic
4. Red flags – CAD (Cervical arterial dissection)

Question 3

What are the 2 frequent intermittent headaches (FIH)?

Answer 3

Question 4

What are 3 types of headaches (neck pain common in headache)?

Answer 4

1. Migraine‐ 75% report neck pain, prodromal
2. TTH
3. Cervigogenic

Contributes significantly to the burden of H/A

• Makes pain and management worse

Question 5

What are 4 causes of neck pain common in headache?

Answer 5

1. ? Comorbid neck condition
2. Cervicogenic headache
3. ? Central sensitisation
4. Referred pain

Question 6

What are the bidirectional pain pathways of headache?

Answer 6

Question 7

What are the 6 typical pain sites of headache?

Answer 7

Question 8

What are upper cervical referral patterns?

Answer 8

Question 9

What are 3 clear diagnostic criteria for headache?

Answer 9

1. Migraine
2. Tension‐type headache
3. Cervicogenic headache

Question 10

What are the 3 characteristics of diagnosis is made on clinical presentations for headache?

Answer 10

1. Lack of lab tests or reliable imaging to diagnose these headaches
2. MRI study of craniocervical structures in cervicogenic headache migraine
3. No differences and few demonstrable lesions

Question 11

What are 4 sections of diagnostic criteria for migraine?

EXAM QUESTION

Answer 11

1. Migraine without aura
   
   1. Headache attacks lasting 4‐72 hours
2. At least 2 of these
   
   1. Unilateral ‐can change sides within or between attacks
   2. Pulsating quality
   3. Moderate to severe intensity ‐ limits daily activity
   4. Aggravated by physical activity
3. At least one of
   
   1. Nausea or vomiting
   2. Photophobia and phonophobia (Noise and light sensitive)
4. Migraine with aura
   
   1. aura precedes headache and lasts approx 5‐ 60mins
   2. unilateral fully reversible visual, sensory or CNS symptoms
5. Episodic migraine
6. Chronic migraine – at least 15 headaches per month, 7 of which must be true migraine

Question 12

What causes migraine headaches? What is the hypothesis?

Answer 12

The cause is not clear. Primary headache‐ no real cause.

Hypothesis:

• Certain parts of the brain hypersensitive‐ employing monoamines eg serotonin and noradrenalin
• Reacts to stimuli such as emotion, sensory impulses, or any sudden change in the internal or external environment. (Hormonal or temp changes)
• Interaction between the brain and the cranial blood vessels.
• Treatment ‐aimed at constriction of dilated arteries to abort each headache as it comes or at the brain itself in an attempt to prevent the headaches

Question 13

What are 5 stages of migraine?

Answer 13

1. Early Warning Symptoms (prodromol) eg mood change
2. Aura 20 – 30% eg visual disturbances
3. Headache +‐ nausea, vomiting and sensitivity to light, sound and smell.
4. Resolution
5. Recovery (postdromol)‐ feeling of being drained about 24 hours/ others may feel energetic

Question 14

What are the 4 triggers of migraine?

Answer 14

1. Dietary Triggers
2. Environmental Triggers
3. Hormonal Triggers
4. Physical and Emotional

Question 15

What are 4 dietary triggers of migraine?

Answer 15

1. missed, delayed or inadequate meals
2. caffeine withdrawal, certain wines, beers and spirits, chocolate, citrus fruits,
3. aged cheeses and cultured products, monosodium glutamate (MSG)
4. dehydration.

Question 16

What are 5 environmental triggers of migraine?

Answer 16

1. bright or flickering lights, bright sunlight
2. strong smells, e.g. perfume, gasoline, chemicals
3. travel, travel‐related stress, high altitude, flying
4. weather changes, changes in barometric pressure
5. loud sounds

Question 17

What are 6 hormonal triggers of migraine?

Answer 17

1. Menstruation
2. Ovulation
3. Oral contraceptives
4. Pregnancy (may worsen or improve
5. Hormone replacement therapy (HRT)
6. Menopause

Question 18

What are 5 physical and emotional triggers of migraine?

Answer 18

1. Lack of sleep or oversleeping
2. illness such as a viral infection or a cold,
3. back, neck pain
4. emotional triggers such as arguments, excitement, stress and muscle tension
5. relaxation after stress (weekend headache).

Question 19

What are 8 Diagnostic Criteria of Tension Headache?

Answer 19

1. headache lasting 30 mins to 7 days
2. pressing, tightening, non pulsating quality
3. bilateral, bandlike headache
4. mild to moderate intensity ‐ may inhibit, but not prohibit activity
5. not aggravated by physical activity
6. no nausea, vomiting
7. photophobia or phonophobia is present
8. other headache forms ruled out

Question 20

What are 4 sections of diagnostic criteria for Tension Headache?

EXAM QUESTION

Answer 20

1. Episodic TTH
   
   1. headache lasting 30 mins to 7 days
2. At least 2 of
   
   1. pressing, tightening, non pulsating quality
   2. bilateral, bandlike headache
   3. mild to moderate intensity ‐ may inhibit, but not prohibit activity
   4. not aggravated by physical activity
3. Both of
   
   1. no nausea, vomiting
   2. no more than one of photophobia or phonophobia
4. Other headache forms ruled out

• Chronic T‐T headache > 15 days per month

Question 21

What 5 causes tension‐type headaches?

Answer 21

The cause is not clear. Some, not all, may be due to tension. Primary headache= no real cause (Eg. emotional- stress, anxiety; physical - clenching)

1. Some triggers
2. Emotional tension, anxiety, tiredness or stress.
3. Physical tension in the muscles of the scalp and neck. poor posture, squinting, clenching
4. Physical factors bright sunlight, cold, heat, noise, etc.
5. Genetics

Question 22

What are 11 Diagnostic Criteria (characterised symptomatically) of Cervicogenic Headache?

Answer 22

Characterised symptomatically:

1. unilateral or unilaterally dominant headache
2. without sideshift (does not switch sides)
3. associated with ipsilateral neck, shoulder, arm , thoracic pain
4. pain begins in the neck
5. not throbbing/ pulsating
6. headache is aggravated by neck related activities movement or postures
7. associated with restricted neck motion
8. temporal association neck pain and headache onset
9. eliminated by cervical diagnostic block
10. possible nausea, phono, photophobia
11. No other headache type accounted for

Question 23

What types of headaches should we treat?

Answer 23

Individuals with cervicogenic, migraine or tension‐type headaches present to physiotherapists for management of their headaches

Question 24

Should we be offering MSK treatment to all headache sufferers presenting for management?

Answer 24

• Evidence of long term benefit of manual therapy and exercise directed to cervical musculoskeletal dysfunction for cervicogenic headache
• Systematic review:
  
  • No convincing evidence for manipulation alone
• Evidence from clinical trials of physical interventions
• No evidence of long term benefit of physical therapies directed to cervical musculoskeletal dysfunction for migraine and tension–type headache

Question 25

What are Differential diagnosis can be challenging with headache?

Answer 25

* Few symptoms unique to one headache type (migraine with aura) * well recognised symptomatic overlap between headache types * migraine and cervicogenic are both unilateral headaches * mental stress and neck position common precipitant of all FIH types * Neck pain – common to all –bidirectional pathway * Neck injury‐ post traumatic headache‐ can be migraine, tension type, cerivogenic or mix

Question 26

What are the 2 alternatives to diagnose cervicogenic headache?

Answer 26

1. demonstrate clinical signs that link a source of pain in the neck with the headache\*\*\*\*\*\* 2. abolition of headache with diagnostic joint or nerve blocks 1. suitable for pre‐neurotomy surgery 2. invasive and expensive for widespread diagnostic use

Question 27

What are 9 musculoskeletal impairments associated with cervicogenic headache?

Answer 27

1. Static postural shape (FHP) 2. Functional postures 3. Restricted range of motion 4. Painful upper cervical joint dysfunction 5. Neural tissue mechanosensitivity 6. Tenderness 7. Impaired muscle function 8. Muscle extensibility 9. Disturbances sensorimotor control system

Question 28

What are 3 musculoskeletal impairments associated with migraine and TTH?

Answer 28

1. Very low level evidence of slightly reduced neck motion in migraine. 2. Low level evidence of reduced neck motion and altered posture in TTH. 3. Moderate to very low levels of evidence indicate other measures to be normal.

Question 29

How well does a physical sign diagnose cervicogenic headache?

Answer 29

1. Tenderness, trigger points lack specificity ‐ present in migraine, tension‐type and cervicogenic headache 2. Little specificity for an isolated physical sign‐ ROM alone lacks specificity 1. Range of movement 1. variability between normal subjects 2. age effects

Question 30

What is a pattern of cervical musculoskeletal dysfunction characterised cervicogenic headache?

Answer 30

Question 31

What are the 2 main characteristics (4/3) of cervicogenic headache (differential diagnosis‐ key to management)?

Answer 31

1. Symptomatic pattern Sjaastad et al 1998 1. Intermittent, side dominant headache, moderate intensity, without side shift 2. Headache is preceded by ipsilateral neck pain 3. Precipitated or aggravated by neck movement or posture 4. Temporal pattern – neck pain only with headache? 2. Pattern of physical impairment in the cervical musculoskeletal system 1. Reduced range of movement 2. Painful segmental joint dysfunction – upper cervical 3. Impaired cervical muscle function

Question 32

What are 5 red flags in differential diagnosis of headache?

Answer 32

1. Severe headache of sudden onset (In patients that don’t usually have headaches) 1. acute subarachnoid haemorrhage 2. spontaneous dissections, vertebral or carotid artery\*\*\* 2. Subacute headache progressively worsening 3. Headache associated with neurological signs or changes in consciousness 4. Temporal headache, onset after 50 years old (particularly in females) 5. Headache not associated with identifiable aetiology * Eg. usually another condition (eg, injury to neck, neck condition)

Question 33

What are the cervical arteries?

Answer 33

Question 34

What is blood supply to the brain from cervical arteries?

Answer 34

Question 35

What are 7 red flag signs and symptoms in differential diagnosis of headache?

Answer 35

1. Acute onset of new pain (headache or neck pain) 2. Generally unwell, fever, night pain, night sweats 3. Cord signs (eg leg weakness, gait disturbance, hand clumsiness) 4. Neck stiffness particularly into flexion 5. Acute vertebral tenderness to palpation 6. Deteriorating neurological signs 7. Also consider: 1. Recent trauma 2. Osteoporosis --\> fracture in the neck --\> causing headache

Question 36

What are 5 characteristics of cervical arterial dissection (CAD)?

Answer 36

1. Includes vertebral (VAD) or internal carotid artery (ICAD) dissection 2. A blood clot forms at the tear site which may embolise or 3. Alteration in blood flow may cause a clot to form and travel to the brain causing a stroke 4. More common in younger people \<45years 5. Rare, incidence CAD 2.97 per 100,000 Associated with stroke

Question 37

What are the 5 characteristics in the recognition of cervical arterial dissection (CAD)?

Answer 37

1. Acute onset new, unusual pain (neck pain or headache) 2. Pain like no other previously experienced 3. Moderate‐severe pain 4. Transient neurological features 1. Balance/gait 2. Speech 3. Visual disturbance 5. Age under 55 years

Question 38

What are 3 concerns for clinicians when treating people with headache?

Answer 38

1. Can present like a musculoskeletal condition (neck pain and headache) 2. Linked with neck manipulation 1. Whether causative or 2. result of missed diagnosis 3. Rare condition but need to be alert

Question 39

What is important in the patient interview for headache? What are 12 features?

Answer 39

* Actively listen to the patient’s headache story (first time VS common occurrence for them) * Match story to the classification criteria * 70‐80% certainty of diagnosis from the history and features of headache * Document appropriate outcome measures 1. Length of history 2. Temporal pattern 3. History of onset 4. Area of pain 5. Nature of pain 6. Onset of headache 7. Aggravating features 8. Relieving features 9. Medication (eg. overuse) 10. General health 11. Other headaches 12. Family history (esp. migraines)

Question 40

What are 4 important assessments in the physical examination (in addition to other assessments) for headache?

Answer 40

1. Static postural shape 2. Functional postures 3. **Restricted range of motion** 1. validity of the Flex Rot test for C1‐2 headache\*\*\* 4. **Painful upper cervical joint dysfunction** 5. Neural tissue mechanosensitivity 6. **Impaired muscle function** 7. Muscle extensibility 8. Disturbances sensorimotor control system * **especially when dizziness present** Differential diagnosis of TMJ * **Need to evaluate the features characteristic to the individual patient to optimise treatment**

Question 41

What are 4 clinical pointers in the diagnosis of cericogenic headache?

Answer 41

1. **Diagnose on symptoms and physical signs** 1. make the pattern fit 2. **Neck tenderness alone is a not a sign** 1. care with manual examination techniques 2. avoid false positive results 3. **Do not aim to reproduce headache** 4. No treatment element should provoke headache 1. Central sensitisation

Question 42

What are 4 examinations of a headache patient?

Answer 42

1. **Establish if the headache is sounding *cervicogenic* in origin** 1. Intermittent, side dominant headache, moderate intensity, without side shift 2. Headache is preceded by ipsilateral neck pain * Precipitated or aggravated by neck movement or posture 2. **Establish precise cervical MS components in the headache** * (postures, movement abnormalities, segmental joint dysfunction, muscle impairments) 3. **Understand provocative factors in work or leisure activities** * these factors must be addressed in management 4. **Establish outcome measures:** Headache Frequency, Intensity, Duration

Question 43

What are 4 decisions about the patient's headache (outcome of patient interview and physical examination)?

Answer 43

1. **Cervicogenic headache** * **​**Physios can treat this (ROM, joint signs…etc) 2. **Not Cervicogenic** ‐ Migraine or tension‐type headache * Cannot treat 3. **Mixed headache** ‐ Cervicogenic + migraine/tension‐type * Can try and treat (while it might not be effective) 4. **Not cervicogenic** ‐ but co‐morbid musculoskeletal signs * Can treat MSK signs but might not affect the headache

Question 44

What are outcomes of assessments of a cervicogenic headache (subjective features and physical examination confirm CGH)?

Answer 44

Question 45

What is your interpretation of processes underlying Jenny’s condition?

Answer 45

* Pain source nocioceptive – referred pain to head from right C1/2 joint secondary to poor cervical and thoracic movement, proprioception and cervical neuromotor control * Contributing factors‐ gym work, sleepin * Need to consider these for management directions.g positions, ergonomics, work

Question 46

What are musculoskeletal impairments in neck pain disorders (cervicogenic dizziness)?

Answer 46

1. Static postural shape (FHP) 2. Functional/work postures 3. Restricted range of motion 4. Cervical joint dysfunction 5. Neural tissue mechanosensitivity 6. Nerve tissue dysfunction 7. Changes in sensory features 8. Changes in muscle behaviour 9. **Disturbances in the sensorimotor control system**

Question 47

What is the neck in terms of dizziness?

Answer 47

Question 48

What are neck afferents vital for sensorimotor control?

Answer 48

Question 49

What are 3 importance of neck afferents?

Answer 49

1. knowledge of head position in relation to the body 2. controlling posture 3. eye head co-ordination

Question 50

What are 3 experiementals disturbances to neck afferents?

Answer 50

1. Anaesthetic injection into cervical joints - ataxia, falling, visual disturbances 2. Vibration cervical muscles - illusions head, vision, gait deviations 3. Experimental neck muscle pain - impaired standing balance

Question 51

What are 4 evidence of physical impairments in sensoriomotor control in neck pain?

Answer 51

1. Altered proprioception 1. Cervical joint position error 2. Cervical movement sense 2. Eye movement control 1. Altered smooth pursuit eye movement with neck torsion (Keep the eyes still while turning the head) 2. Gaze stability 3. Eye head co-ordination, Trunk head co-ordination (Keep the head still while turning the trunk) 4. Standing balance- static and dynamic

Question 52

What are 7 causes abnormal afferent input in neck disorders?

Answer 52

1. Direct damage from trauma (joint or muscle trauma) - Afferents disturbance 2. Functional impairment in muscles 3. Morphological changes in the muscles -Fatty infiltration, muscle atrophy 4. Inflammatory mediators 5. Altered muscle activity 6. Pain 7. Sympathetic nervous system - stress

Question 53

What are 6 implications of abnormal afferent input in neck disorders?

Answer 53

1. Neck vital sensorimotor control 2. May cause dizziness, visual disturbances in neck pain 3. May cause altered head, eye movement control and balance in those with neck pain 4. Especially in those with trauma, dizziness 5. May be a driver of the problem 6. Implications for management

Question 54

Who is the population that is affected?

Answer 54

1. Evidence of impairment in sensorimotor control in neck pain of both traumatic and idiopathic origin 2. More common in association with trauma 1. whiplash injuries 2. other significant injury (fall, blow) 3. Less common in idiopathic neck pain 4. Common in idiopathic neck pain with associated cervical dizziness 5. Neck pain complaining of dizziness

Question 55

What are 2 symptoms of neck pain

Question 56

What are 3 descriptions of cervicogenic dizziness?

Answer 56

1. vague unsteadiness – true vertigo is rare 2. episodic; often lasts only minutes 3. close temporal relationship neck pain- Worse neck pain = worse headache

Question 57

What are 3 exacerbations of cervicogenic dizziness?

Answer 57

1. neck pain; headache 2. neck movement 3. neck positions

Question 58

What are 4 concurrent symptoms of cervicogenic dizziness?

Answer 58

1. headache 2. nausea 3. blurred vision 4. difficulties concentrating

Question 59

What are 6 symptoms that are NOT cervicogenic?

Answer 59

1. vertigo/true spinning 2. true hearing loss 3. neurological signs 4. double vision 5. spots in eyes 6. red eyes

Question 60

What are clinical tests to differentiate cervicogenic dizziness?

Answer 60

Lacking clinical tests 1. Used current gold standard 2. Excluded other causes 3. Neck pain and dizziness occur together 4. Neck pain, trauma or disease 5. If trauma- close onset dizziness Findings/ Clinical tests differentiated were 1. Lightheaded 2. Pain on P/E upper cervical spine 3. JPE \>4.5 ° at least one direction 4. \>2 °/sec nystagmus cervical torsion test 5. RCT – criteria for inclusion 1. Excluded all other causes 2. Imbalance or unsteadiness – not vertigo 3. Neck pain and or stiffness 4. Dizziness provoked neck movements or positions 5. Signs cervical M/S 6. Response to SNAG DHI – looking up, quick head movements and no fear to leave house alone

Question 61

What is vertebrobasilar insufficiency (VBI)?

Answer 61

Insufficiency of blood flow to the hind brain characterised by typical signs and symptoms

Question 62

What are differential diagnosis of cervicogenic dizziness?

Answer 62

1. Vertebral artery dissection 2. VBI 3. Mild head injury/concussion 4. Vestibular migraine 5. Vestibular neuritis 6. Acoustic neuroma 7. BPPV 8. Perilymph fistula 9. Menieres disease 10. Labyrinthyne concussion 11. Visual 12. Psychogenic 13. Other medical conditions 14. Description 15. Frequency 16. Duration 17. Severity 18. Loss of balance 19. Exacerbating features 20. Concurrent symptoms 21. Onset 22. History 23. Past history trauma 24. Present past 25. Medical history

Question 63

What are the 4 parts of the vertebral artery?

Answer 63

1. V1‐ Branches from the subclavian artery and travels between Longus Colli and Ant scalene to enter transverse foramen of C6 2. V2‐ Passes up in transverse foramen C6 to C1 3. V3‐ Groove of posterior arch of C1 4. V4‐ Enters skull, pierces dura and arachnoid. Joins with opposite VA at base of pons to form basilar artery

Question 64

What are the 3 potentoal lesion sites for vertebral artery?

Answer 64

Question 65

1. VA is vulnerable to positional compromise with contralateral rotation especially at C1‐2 level 2. Can result in VBI especially if the opposite VA is narrowed or diseased

Question 66

What are the 2 causes of VBI (5/2)?

Answer 66

1. Atherosclerosis 1. Most common cause 2. Affects **older** people (70‐80yrs) 3. Narrowing of blood vessels 4. May be a precursor to stroke 5. 25% of all strokes are due to VB artery occlusion (other 75% occur in the carotid artery/MCA) 2. Head position 1. May be aggravated by head and neck position 2. Manual therapy treatment positions ± manipulative thrust may place stress on these arteries

Question 67

What are the common signs and symptoms of VBI? **EXAM QUESTION**

Answer 67

Question 68

What are 3 main VAD/VBI physical examination?

Answer 68

1. VBI tests 2. Cranial nerve examination 3. Co‐ordination

Question 69

What are VBI tests as VAD/VBI physical examination?

Answer 69

APA sustained rotation/extension

Question 70

What are 8 cranial nerve examination as VAD/VBI physical examination?

Answer 70

1. Optic Nerve (II) – Peripheral focus 2. Oculomotor, Trochlear, Abducens (III, IV, VI) – Smooth pursuit 3. Trigeminal (V) – Bilateral forehead sensation (eyes closed) 4. Facial (VII) – Frown/smile 5. Vestibulocochlear (VIII) – Rub finger/thumb next to ear (eyes closed) 6. Vagus (X) – Soft palate/uvula elevation‐ say AAGH 7. Spinal accessory (XI) – SCM/Traps strength 8. Hypoglossal (XII) – Tongue out

Question 71

What are 2 coordination test as VAD/VBI physical examination?

Answer 71

1. Pro/supination 2. Finger to nose

Question 72

What are 6 characteristics of VA physical (positional) testing?

Answer 72

1. Tests the ability of the vertebrobasilar system to maintain hindbrain perfusion and adequacy of collateral supply 2. NOT a test for dissection or safety with manual therapy 3. All age groups may be susceptible 4. Remember these are provocative tests 5. Minimum reliance on physical testing 6. History is main indication 7. Controversial because does not tell you about risk of dissection and a negative test does not imply safety with manual therapy or manipulation

Question 73

What are 4 indications for physical testing?

Answer 73

1. Any patient whose symptoms may indicate vertebrobasilar insufficiency 2. All elderly patients with marked degenerative changes 3. Pre manipulation (high velocity technique [HVT]) 4. Prior to any technique that may compromise the VA (eg end range positions) NB: Only undertaken when VBI symptoms are vague or unclear Intermittent dizziness or unsteadiness = suitable

Question 74

What are the 5 steps of positional testing? What is a positive response?

Answer 74

1. Rotate head to one side and hold sustained not less than 10 secs unless symptoms provoked (sustain longer if indicated) 2. Wait 10 secs on return from neutral (latency of symptoms possible) 3. Repeat to other side, hold 10 secs 4. Wait 10 secs in neutral 5. Patient’s eyes should remain **open** – nystagmus * Gaze into patient's eyes **Positive response: onset of dizziness, nystagmus, pre‐sycope**

Question 75

What are 5 assessments in the cervical musculoskeletal examination?

Answer 75

Neck related dizziness (confirm dizziness coming from the neck) 1. Cervical range of motion, kinematics\* 2. Flexion rotation test \* (Upper cervical --\> might be an issue) 3. Manual examination\* esp upper cervical, SNAG 4. Cervical neuromotor control/ posture – neck, scapula, 5. CCFT\* 6. Cervical and scapular muscle strength/ endurance \* Good discriminatory tests

Question 76

What are 6 assessments in the cervical sensorimotor examination?

Answer 76

* VBI * Neck torsion vs en bloc\* Sensori‐motor 1. Joint position sense (\>4.5°)\* 2. Movement sense 3. Balance 4. Oculomotor 1. Smooth pursuit neck torsion\* 2. Gaze stability 5. Eye head co‐ordination 6. Trunk head co‐ordination\* 7. +‐ Vestibular tests Hallpike Dix‐ BPPV, Others if requir\*ed Good discriminatory tests

Question 77

What is the cervical joint reposition error?

Answer 77

Target (between green or yellow region- Normal = 4.5 degrees) 90cm away from laser Close eyes Turn head and reposition head back to neutral Can re-correct if not suitable 3 (consistent) attempts

Question 78

What are the 6 steps of the cervical joint reposition error?

Answer 78

1. Sitting blindfolded/eyes closed 2. Laser pointer/ torch 3. Ensure standard distance away from target‐ 90 cm. 4. Concentrate on the straight ahead position 5. Move head slowly as far as comfortable and return back to the neutral straight ahead position as accurately as possible. 6. Repositioning to neutral from left and right rotation, flexion and extension

Question 79

What is cervical JPE?

Answer 79

Laser method reliable and repeatable 80% healthy \< 4.5° 80% neck pain \> 4.5° Convert cm to degrees (if needed) 7.1 cm at 90cm = 4.5 degrees Tan -1 distance/90cm = angle

Question 80

How ca cervical movement sense/accuracy be measured?

Answer 80

Track a pattern/path * Timed or how many times they come out of the lines * \>9-10 errors OR \>25 secs

Question 81

What is the smooth pursuit neck torsion test? What is a positive test?

Answer 81

Patient focuses on target- move target visual angle of 40 degrees crossing the midline left to right and back at a speed of 20 degrees per second * Compensation: quick catch up saccades (as cross midline) * 2 secs from one side to the other (eyes following smoothly) --\> following a slow moving object * Keep head still in neutral * Keep head still and turn trunk --\> repeat test (torsion position to R or L) * Neck should not influencing eyes * **+ve test: Normal in neutral but worst in torsion position to R or L**

Question 82

What is a SPNT?

Answer 82

* Compare eye follow head neutral vs neck torsion * Altered ability to follow target when neck in torsion compared to neutral * Catch up saccades, blurred vision, increased difficulty, may be worse one side compared to the other – recently validated against EOG assessment

Question 83

What are 8 important physical examination for cervical differential diagnosis?

Answer 83

1. Presentation/ History 2. Cervical range of motion 3. VBI testing, +- cranial nerves, co-ordination 4. Neck torsion vs en bloc 5. Musculoskeletal examination 1. Manual examination 2. Cervical neuromotor control/ posture 6. Sensori-motor- clinical measures 1. Joint position sense ±neck torsion/ movement sense 2. Smooth pursuit neck torsion 3. Trunk head coordination 4. Oculomotor 5. Balance and gait 7. +- Vestibular tests Hallpike Dix- BPPV, head thrust, head shaking nystagmus, motion sensitivity 8. +- Neurological exam

Question 84

What are cervicogenic dizziness subjective features and physical examination suggestive of CGD?

Answer 84

Question 85

What are 7 referrals if the diagnosis is not fitting cervical dizziness?

Answer 85

1. medical review 2. neurologist- vestibular migraine 3. vestibular testing 4. hearing tests 5. further investigations 6. vestibular physiotherapist 7. behavioural optometrist If mixed symptoms and benign - trial of management addressing cervical spine and sensorimotor control- similarities in approach * Eg. if they have vestibular symptoms, trial improving neck pain first as vestibular exercises/management can aggravate neck pain Should see changes with improvements in neck and sensori-motor

Question 86

What is the differential diagnosis of patients with mild head injurt/concussion? What are 3 other considerations?

Answer 86

- likely mixed forms Cervical (M/S and sensorimotor) and vestibular physio in patients post sports concussion with persistent symptoms of dizziness, neck pain and or headache 1. Primary cervical --\> secondary vestibular * Stop moving neck and now starting to move again 2. Primary vestibular --\> secondary cervical * neck complaints associated with a primary vestibular problem * Stop moving neck and now starting to move again 3. Cervical ‐ compensation for vestibular * implications elderly, falls prevention, vestibular clients, concussion

Question 87

What are 3 other consideratopms for cervical pain?

Answer 87

1. Primary cervical --\> secondary vestibular * Stop moving neck and now starting to move again 2. Primary vestibular --\> secondary cervical * neck complaints associated with a primary vestibular problem * Stop moving neck and now starting to move again 3. Cervical ‐ compensation for vestibular implications elderly, falls prevention, vestibular clients, concussion