Dizziness, Unsteadiness, Visual Disturbances, and Sensorimotor Control in Traumatic Neck Pain

[ clinical commentary ]
JULIA TRELEAVEN, PhD, BPhty1
Dizziness, Unsteadiness, Visual

Disturbances, and Sensorimotor
Control in Traumatic Neck Pain
S
ymptoms such as dizziness, unsteadiness, and visual incidents of relatively low force (ie,
disturbances and signs of altered head and eye low speed and no concussion, loss
Downloaded from www.jospt.org at on June 30, 2021. For personal use only. No other uses without permission.
movement control and postural stability are common in of consciousness, or a direct blow
to the head), sensorimotor control
those following neck trauma, especially in those with
disturbances due to CNS or periph-
persistent pain.115 Understanding these signs and symptoms and eral vestibular system injury are
potential origins is important for assessment and relevant rehabilitation. less likely,43,104,107 in contrast to the more
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Suggested causes include altered sensorimotor control, vertebral likely damage and subsequent functional
artery dissection or insufficiency, psychosocial factors such as anxiety and impairment of the abundant cervical
joint and muscle structures and related
fear avoidance, and medication use.34,107,113 system (CNS) to provide appropriate mo- receptors.51,111,129 These cervical receptors
Among these factors, research to date in- tor output to control head and eye move- provide important input and have unique
dicates that the primary cause is most ment and postural stability.5 Potential central and reflex connections to the ves-
likely altered sensorimotor control.114 damage or impairment to components of tibular, visual, and sensorimotor control
The sensorimotor control system the sensorimotor control system (cervi- systems (FIGURE 1).18,82
comprises input from the visual, vestibu- cal spine, vestibular system, or CNS) is After traumatic neck injury, distur-
Journal of Orthopaedic & Sports Physical Therapy®
lar, and proprioceptive systems, particu- possible following traumatic incidents bances in sensorimotor control, primar-
larly the richly innervated cervical spine, such as a whiplash injury. However, ily via altered cervical input, may occur
which is integrated in the central nervous based on animal and human models, in due to a combination of factors. Apart
from direct trauma, factors associated
with the trauma, such as inflammation,110
UUSYNOPSIS: There is considerable evidence assessment of those with traumatic neck pain,
functional impairment,32 morphological
to support the importance of cervical afferent including those with concomitant injuries such as
dysfunction in the development of dizziness, concussion and vestibular or visual pathology or changes to musculature,29 pain,66 and
unsteadiness, visual disturbances, altered balance, deficits. Once adequately assessed, appropriate psychological distress,79 may alter cer-
and altered eye and head movement control tailored management should be implemented. vical input or CNS representation. This
following neck trauma, especially in those with Research to further assist differential diagnosis can influence cervical reflex connections
persistent symptoms. However, there are other and to understand the most important contribut- to the visual and vestibular systems and
possible causes for these symptoms, and second- ing factors associated with abnormal cervical result in subsequent secondary distur-
ary adaptive changes should also be considered afferent input and subsequent disturbances to the
in differential diagnosis. Understanding the nature bances.97 Immediate sustained change in
sensorimotor control system, as well as the most
of these symptoms and differential diagnosis of cervical input to the sensorimotor control
efficacious management of such symptoms and
their potential origin is important for rehabilita- system following neck trauma may be a
impairments, is important for the future. J Orthop
tion. In addition to symptoms, the evaluation more common cause of dizziness, visual
Sports Phys Ther 2017;47(7):492-502. doi:10.2519/
of potential impairments (altered cervical joint disturbances, and unsteadiness, as well as
jospt.2017.7052
position and movement sense, static and dynamic
UUKEY WORDS: cervical spine, proprioception,
changes in cervical proprioception, head
balance, and ocular mobility and coordination)
should become an essential part of the routine WAD, whiplash and eye movement control, and postural
stability, although other causes of senso-
1
Neck Pain and Whiplash Research Group, Division of Physiotherapy, School of Health and Rehabilitation Sciences, University of Queensland, St Lucia, Australia. The author
certifies that she has no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the
article. Address correspondence to Dr Julia Treleaven, Division of Physiotherapy, School of Health and Rehabilitation Sciences, University of Queensland, St Lucia, QLD 4072
Australia. E-mail: j.treleaven@uq.edu.au t Copyright ©2017 Journal of Orthopaedic & Sports Physical Therapy®
492 | july 2017 | volume 47 | number 7 | journal of orthopaedic & sports physical therapy

Eye Sensorimotor control
Afferent integration CNS
movement
and tuning
control
Cervico-ocular Vestibulocollic
reflex reflex
Visual system Cervical afferents Vestibular system FIGURE 2. Cervical joint position error in neck
torsion. A laser is placed on the sternum and
Vestibulo-ocular reflex projected onto a target 90 cm away. The head is
gently held still by the examiner while the individual
Cervicocollic actively rotates the trunk as far as comfortable and
reflex then returns to the starting position as accurately
Head as possible with vision occluded. The difference in
Cervical motor movement degrees between the starting and ending positions
Postural control is the joint position error.
stability Tonic neck
reflex Vestibulospinal
reflex
Lower-limb motor sistance of vision.88 Greater errors have
been shown in individuals with both
FIGURE 1. Proposed schema of cervical afferent involvement in sensorimotor control. Abbreviation: CNS, central INP and persistent WAD, although er-
nervous system.
rors are greater in those with neck trau-
ma,24 especially in those with moderate
rimotor control disturbances should also read, visual fatigue, difficulty judging to severe pain and disability.100 Further,
be considered in the differential diagno- distances, and light sensitivity, are fre- Treleaven et al121 found that individuals
sis process. The present commentary will quently reported in whiplash-associated with persistent WAD and symptoms of
explore current evidence for symptoms disorder (WAD) and idiopathic neck pain dizziness had greater errors than those
and signs, clinical assessment, differen- (INP) without trauma.124 Interestingly, not complaining of dizziness, suggest-
tial diagnosis, and management of senso- these are symptoms similar to those ex- ing that these symptoms may be due to
rimotor control disturbances associated perienced by some individuals with post- greater abnormal cervical afferent input.
with traumatic neck pain. concussion syndrome. But, in those with However, while JPS testing is thought to
postconcussion syndrome, additional be a measure of cervical proprioception,
EVIDENCE OF SENSORIMOTOR visual symptoms, such as losing the loca- deficits have also been seen in those with
DISTURBANCE tion on the page and ineffective reading vestibular pathology in some114 but not
speed, are also often reported.61,98 Also, other studies.67 More recently, to better
Symptoms true double vision, which is common in control for vestibular function, an alter-
S
ymptoms characteristic of cer- individuals with vertebrobasilar insuf- native test of trunk relocation on a stable
vicogenic dizziness and unsteadi- ficiency, is not commonly reported in head has been developed (FIGURE 2). Al-
ness are often present in patients traumatic neck pain.124 though the test has promise to assist with
following neck trauma, especially in those Interestingly, other symptoms often differential diagnosis, additional research
with persistent pain.114,121 True vertigo or associated with postconcussion syn- is required before it can be advocated for
spinning, typically attributed to vestibu- drome,61 such as headache, poor concen- clinical and research use.12 Interestingly,
lar dysfunction, is rarely described, and tration,105 and fatigue,106 are also common position sense deficits have not been iso-
generally the dizziness is described as in those with traumatic neck pain. It is lated to the neck in this population, with
vague unsteadiness or light-headed- possible that this is due to concomitant deficits also seen in the shoulder and
ness.121 Further, exacerbating factors are head trauma associated with neck trauma elbow in some patients with traumatic
generally related to increased neck pain, or vice versa, where potential neck trau- neck pain.57,91
headache, or neck-related movement and ma is associated with head trauma.30,62,69 Cervical Movement Accuracy Several
activity.114,121 Such symptoms have also studies have looked at accuracy of fine
been associated with reports of loss of Cervical Proprioception motion control in the neck of those with
balance and falls in some individuals.121 Joint Position Sense Joint position sense traumatic neck pain as another mea-
Symptoms relating to the visual sys- (JPS) is defined as the ability to relocate sure of proprioception. Kristjansson et
tem, such as needing to concentrate to the natural head position without the as- al59 and Kristjansson and Oddsdottir60
journal of orthopaedic & sports physical therapy | volume 47 | number 7 | july 2017 | 493

demonstrated less accuracy in tracing a measure; therefore, as is, vertical align- cits for stance and complex rather than
computer-generated movement pattern ment perception may not be a suitable simple gait tasks.36 This may suggest a
with the head in those with traumatic measure of cervical proprioception in combined cervical/vestibular deficit in
neck pain when compared to both a those with traumatic neck pain.125 this population.
control group and individuals with INP.
These authors also found that these im- Standing Balance Eye Movement Control
pairments did not specifically relate to Static Balance Several studies have Several alterations in oculomotor control,
other signs and symptoms associated demonstrated disturbed postural stabil- including disturbed eye follow, gaze sta-
with WAD and seem to either develop ity in individuals with traumatic neck bility, eye-head coordination, vergence,
over time or persist.76 Woodhouse et al,132 pain,8,68,95,96 especially in those with symp- saccades, and ocular reflex activity, have
using a stationary movement pattern, toms of dizziness.120 Balance disturbances been associated with traumatic neck
also demonstrated decreased accuracy have also been related to neck muscle pain. Such abnormalities can be pres-
in individuals with WAD compared to a fatigue in those with WAD.99 Deficits are ent in disorders of the vestibular system,
control group and individuals with INP. noted in most testing conditions, includ- disorders of the CNS, and as a result of
Recently, accuracy in following a moving ing when standing in comfortable, nar- abnormal afferent input from the cervical
target in a virtual environment has been row, and tandem stances, and especially spine.47,73,119
shown to be somewhat sensitive and spe- when vision is occluded. Sway is usually
cific to those with neck pain.4 To date, no increased in the anterior-posterior di- Smooth-Pursuit Neck Torsion
specific differences in those with trau- rection, indicative of somatosensory im- Similarly to balance tests, neck torsion
matic neck pain compared to INP have pairment,94 although in more difficult has been used to demonstrate a cervical
been noted, but this is a continued area tests, a stiffening strategy and less sway, afferent cause in some tests. Accordingly,
of investigation (FIGURE 3).4 compared to those with INP, has been abnormalities in eye follow or smooth
Vertical Alignment Perception Distur- observed.36 These static balance distur- pursuit when tested in the neck torsion
bances in the ability of individuals with bances are likely primarily due to cervical position, compared to a neutral neck
neck pain to correctly identify true ver- afferent dysfunction rather than vestibular position, have been seen in those with
tical using the rod and frame test are function, as they differ in those with uni- WAD but not in those with central or pe-
thought to be suggestive of disturbed lateral vestibular pathology.122 In addition, ripheral vestibular pathology.111,122 These
cervical proprioception.3 It has been sug- individuals with WAD, in a test specifically abnormalities were also greater in those
gested that those with traumatic neck designed to isolate the cervical afferents, with whiplash who also had symptoms of
pain may have greater deficits. But, a had increased sway with the neck in a tor- dizziness.119 In other studies, close associ-
recent study demonstrated altered verti- sioned (trunk turned, head still), rather ations were noted between performance
cal perception in those with INP but not than in a head-rotated, position when on the smooth-pursuit neck torsion
WAD.125 It was suggested that this might compared to a neutral head position.133 (SPNT) test and disturbance of reading,
have been due to the complexity of the These alterations were not seen in either driving, and cognitive tasks.41 This sug-
asymptomatic individuals or those with gests that some common symptoms of
vestibular pathology.127,133 This suggests posttraumatic neck injury might mani-
that this test may be specific for those with fest from disturbed sensorimotor control
cervical-related balance deficits. due to abnormal cervical afferent input.
Dynamic and Functional Balance Dy- However, others using a fully automated
namic and functional balance can also analysis of SPNT26,54,58 have not found
be affected. Impairments in the step test, deficits to the same extent. This may re-
timed 10-m walk with and without head flect the importance of trained observers
turns, tandem walk, and stair walking, to determine and extract the appropriate
as well as delayed corrective responses elements of the signal for analysis. A test
to destabilizing perturbations while sit- to address this problem may be the cervi-
ting and stepping in place, have been cal torsion test. Recently, it has been sug-
FIGURE 3. Cervical movement accuracy. The
demonstrated in those with persistent gested that nystagmus of greater than
individual follows a moving target at 10°/s in flexion,
extension, and rotation to the left and right while
WAD.13,19,101 Interestingly, similar pat- 2°/s during sustained neck torsion posi-
immersed in a virtual reality environment. Sensors terns of balance impairment were present tions may be an alternative and more sen-
in the head-mounted display measure the difference in individuals with traumatic neck pain sitive method than SPNT to demonstrate
between the target and the individual’s head position with and without concussion, but those these abnormalities.67 However, this was
to give a measurement of accuracy.
with concussion had greater balance defi- done in individuals with cervicogenic diz-

ziness and not specifically in those with disturbance as the cause of the deficits. prognosis in those with traumatic neck
traumatic neck pain. Interestingly, when this is seen in people pain.15,50,77,83,100 Thus, appropriate as-
While abnormalities in smooth pursuit with vestibular pathology and in the el- sessment, differential diagnosis, and
with the neck in torsion have been linked derly, it is thought to be a compensation management of clinical features may be
with cervical afferent disturbances, it is for a decrease in vestibulo-ocular reflex important, especially when trying to pre-
possible that smooth-pursuit abnormali- gain.71 However, this compensatory re- vent transition to chronicity.113
ties in the neutral neck position or altered sponse has not been seen in individu-
saccadic eye movement may reflect CNS als with WAD and may be an important CLINICAL ASSESSMENT
impairment,130 which can occur in isolat- cause of disturbances to the visual sys-
G
ed severe cases of persistent pain follow- tem.71 Further, there is some evidence that iven the current evidence, ear-
ing neck trauma.129 Further, medications reflexive neck muscle activity seen during ly assessment of cervical joint posi-
and some psychological conditions can eye movements, likely mediated by this tion and movement sense, balance,
influence eye movement control, although reflex, is altered in those with WAD.7 and oculomotor and coordination dis-
this should not be influenced by neck po- turbances55,115 should be routine in all pa-
sitions such as neck torsion.39 Eye-Head-Body Coordination tients with traumatic neck pain, not just
Gaze Stability Decreased range of head Decreased head velocity during tasks in- in those complaining of symptoms. There
movement while attempting gaze fixa- volving head-eye coordination, compen- is evidence that these features occur soon
tion, measured by head and eye move- satory head movements during isolated after injury and are not a response to on-
ment sensors, has also been seen in those eye rotation,117 reduced precision in an going pain and disability.14,51,100 While
with traumatic neck pain.44,117 Recently, eye-head-hand coordination task,92 and there is abundant evidence that these
physical therapists’ ratings of visually as- impairment in trunk-head coordination signs and symptoms are most likely due
sessed head and eye movement control (ie, moving the head and trunk indepen- to altered cervical afferent input to the
tests, such as gaze stability, were shown dently) have been identified in those with sensorimotor control system, in some
to be reliable and also demonstrated im- traumatic neck pain.126 individuals, there is potential for other
pairments in those with neck pain, which causes, and thus differential diagnosis
included traumatic neck pain,22 enabling Sensorimotor Incongruence is important to direct appropriate man-
clinical application of these measures. Sensorimotor integration has been sug- agement. Other considerations are the
However, unlike SPNT, there is not yet a gested to be affected in those with trau- potential for primary cervical afferent
specific test to isolate a cervical afferent matic neck pain as a result of impaired disturbances leading to secondary ves-
cause of gaze stability disturbances. cervical proprioception and has been as- tibular impairments,37,97 primary vestibu-
Ambient Visual System Damage to the sessed via altered perception of distorted lar or visual impairments influencing the
ambient visual system, important for spa- visual feedback or laterality judgment cervical spine,2,89,131 and the presence of
tial orientation, has also been suggested tasks. During a distorted arm coordina- concomitant cervical, visual, vestibular,
as a possibility following a whiplash in- tion task, sensorimotor incongruence was and or mild brain deficits such as those
jury.78 Convergence and accommodation seen in those with both acute and chron- seen following concussion.30,69
insufficiency and eye alignment malfunc- ic traumatic neck pain.20,21 However, a
tions have been demonstrated in some study using laterality judgment tasks did DIFFERENTIAL DIAGNOSIS
following a whiplash injury.11,102 Together, not show impairments,81 and another, in
I
these symptoms can be labeled as post- fact, found improved reaction times and t can be difficult to precisely de-
trauma visual syndrome.78 Nevertheless, similar accuracy to controls in those with termine the causes of sensorimotor
research into this area is in its infancy. traumatic neck pain.90 The authors of the control disturbances in those with
In those with concussion, more work later study suggest that strategies to com- traumatic neck pain due to potential
has been done, and oculomotor deficits, pensate for altered proprioception may concomitant deficits (visual or vestibu-
thought to be related to cortical or sub- have led to this finding. lar), as well as secondary adaptations
cortical function, have been shown to be within the sensorimotor control system.
common, especially early postinjury,80,128 PREDICTORS OF Further, certain medications and fac-
and may be a persistent feature in some.48 POOR RECOVERY tors such as anxiety can perpetuate or
Cervico-ocular Reflex An increased gain cause disturbances via several suggested
T
of the cervico-ocular reflex has also been here is some evidence that mechanisms.39,79
demonstrated in individuals with whip- symptoms such as dizziness and It is important to consider that even
lash70 and recently in those with INP,23 signs of sensorimotor control dis- in low-force situations generated during
supporting the theory of cervical afferent turbances may be indicative of poorer traumatic neck injury, there is potential

for vestibular migraine should also be
Central vestibular
Oculomotor, vestibulospinal pathways considered in the chronic phase.63,64 Re-
Cerebellum ferral for a more thorough investigation
Brain stem of the vestibular, CNS, or visual systems
Cerebral cortex
and appropriate medical management
may then be warranted.
Peripheral vestibular Ocular Forces required
Utricle, saccule, semicircular canals At present, consensus opinion is that
BPPV tests to identify vestibular or CNS dys-
Labyrinthine concussion
Perilymph fistula 60-160 g function have stronger clinical utility
than tests for cervical causes of dizziness
and sensorimotor control disturbances.87
Nevertheless, there are some emerging
Cervical Forces required objective tests that may also help differ-
Cervical afferents ential diagnosis of cervicogenic causes of
Muscles, joints, ligaments

Vertebral artery the disturbances, with a cluster of tests
4.5 g
likely to be more discriminatory than
FIGURE 4. Potential areas of damage during traumatic neck pain, especially during situations with high forces that individual tests.67 For example, tests of
can lead to altered sensorimotor control. Abbreviation: BPPV, benign paroxysmal positional vertigo. smooth pursuit,111,119 balance,133 and JPS12
in torsion (head still, trunk rotated) may
damage to many neck structures,107 in- the clinician should interview the patient be useful in indicating the extent of the
cluding the vertebral artery. Although and choose tests accordingly to consider cervical spine contribution to the deficits.
vertebral artery dissection is rare, it is these possible causes of the disturbances This is expected when signs and symp-
potentially dangerous9,56 and should al- and to determine the most likely cause. toms are increased when the individual
ways be considered in the differential di- In general, cervicogenic dizziness is positioned in torsion compared to
agnosis. Recent work by Thomas108 and should be episodic, have a close temporal the neutral neck position. Similarly, in
Thomas et al109 suggests that this should relationship to neck pain, be brought on a recent study, the cervical torsion test
be suspected, particularly in those with by specific neck movements or positions was found to be one of a cluster of use-
severe unilateral neck pain and headache rather than whole-body movements or ful discriminating tests for cervicogenic
and those who report transient or ongo- other factors such as increased intracra- dizziness. In this test, the head is held
ing specific neurological dysfunction. nial pressure or anxiety, and be described still and the patient rotates the trunk
However, when higher forces or a di- as an unsteadiness or light-headedness, to the left, then returns to neutral, then
rect blow to the head occur, additional in- not vertigo. Thus, the description, tem- rotates the trunk to the right, and finally
juries, such as concussion and/or damage poral pattern, and aggravating factors returns to neutral. Each position is sus-
to the CNS or visual or peripheral vestibu- of the symptoms,16,17,53,121 as depicted in tained for 30 seconds, and nystagmus of
lar apparatus, are more likely (FIGURE 4).74 the TABLE, can be useful to determine greater than 2°/s in any of the 4 positions
It has been suggested that up to 35% of the need for additional tests, such as the is considered a positive test.67 Conversely,
those with traumatic neck pain associated head thrust or head impulse test, and reproduction of symptoms during en bloc
with higher forces may have peripheral head shaking nystagmus, dynamic visual tests (ie, simultaneous trunk and head
vestibular damage (eg, benign paroxys- acuity for peripheral vestibular pathol- rotation) should indicate a noncervical
mal positional vertigo, damage to the ogy, or the Dix-Hallpike or head-roll ma- cause.49 Associated findings of musculo-
endolymphatic sac, or a perilymph fistu- neuvers for benign paroxysmal positional skeletal impairment in the cervical spine,
la).25,31,43,112 Further, there is some sugges- vertigo.49 Spontaneous and gaze-evoked especially the upper cervical spine, have
tion that injuries induced by axial rotation nystagmus, as well as other oculomotor been shown to be important in those with
versus linear acceleration during the acci- tests such as eye tracking, skew deviation, cervicogenic dizziness67,86; however, this
dent may result in different types of neu- and saccades, may be required if central is usually present in those with traumatic
ro-otological injury.40 Vestibular migraine vestibular pathology or brain injury is neck pain and thus not specifically help-
might also be triggered by the injury as- suspected.38,49 Tests of accommodative ful for differential diagnosis in this group.
sociated with traumatic neck pain.65,72 function such as near-point convergence, A potential schema for differential diag-
Conversely, in those who have a primary often positive in those with concussion, nosis, possible subjective and objective
diagnosis of concussion, associated neck should be included in those with visual test findings, and subsequent manage-
trauma should also be considered as a po- symptoms exacerbated by eye movement that may be required are presented
tential cause of some symptoms.30,69 Thus, ments alone.42,80 The diagnostic criteria in the TABLE.

Differential Diagnosis and Suggested Management of Sensorimotor
TABLE
Control Disturbances in Those With Traumatic Neck Pain
Cervical Vertebral Artery BPPV Perilymph Fistula Peripheral Vestibular Central Vestibular Psychological
Description • Unsteadiness • Fainting • Vertigo • Vertigo • Vertigo • Dysequilibrium • Floating
• Light-headedness • Vertigo dizziness • Dysequilibrium • Unsteadiness • Motion intolerance • Rocking
• Motion intolerance • Motion intolerance • Fullness in head
Frequency • Episodic • Episodic • Discrete • Episodic/constant • Episodic vertigo • Varies • Varies
attacks • Constant unsteadiness
Duration • Minutes to hours • Several seconds • Seconds • Constant • Seconds to minutes • Varies • Varies
Exacerbated • Increasing neck pain • Sustained neck • Rolling in • Visual challenges • Head positions or • Spontaneous or • Stress
• Neck movement extension and/or bed • Increased intracra- movement provoked • Anxiety
rotation • Looking up nial or atmospheric • Hyperventilation
• Lying down pressure (eg,

blowing nose)
• Loud noises
Relieved • Decreasing neck pain • Neck back to • Subsides if • Avoiding above • Head/body still • Varies • Relaxation
neutral staying in activities, rest
provoking
position
Associated • Blurred vision • Dysarthria • Nausea • Unilateral tinnitus • Nausea • Nausea • Lump throat
symptoms • Nausea • Hemiparesis • Vomiting • Aural pressure • Vomiting • Imbalance • Heart palpitations
• Neck pain • Dysesthesia • Hearing loss • Hearing loss • CNS signs • Tight chest
• Diplopia • Tinnitus
• Dysphagia • Ear fullness
• Drop attacks
• Nystagmus
• Nausea
• Numbness
Suggested • Abnormal cervical • VA dissection/ • Debris in • Leak of perilymph • Vascular injuries • Brain stem • Anxiety
cause afferent input insufficiency endolymph fluid into middle • Fractures • Cerebellum • Stress
ear
Primary • Cervical musculo- • Possible positive • Positive • Positive pressure • Head impulse • Spontaneous or gaze- • None
objective skeletal impairments VBI tests Dix-Hallpike test • Head-shake DVA evoked nystagmus
findings • JPE, >4.5° • VAD: unilateral or head roll • Positive Valsalva • Oculomotor deficits*
• Increased sway severe headache test • Ataxia
• Balanced neck • Transient
torsion neurological
• Positive SPNT disturbances
• Positive cervical relating to VA
torsion test function
• Positive trunk-head
coordination test
• Absence of other
findings
Suggested • Cervical musculo- • Referral to • Epley or • Referral to ENT • Tailored vestibular • Tailored rehabilitation, • Meditation
treatment skeletal and tailored neurologist BBQ roll • Surgery rehabilitation, central oculomotor, vestibular, • Mindfulness
sensorimotor maneuver adaptation, habituation balance, and gait • Stress management
• Cervical musculoskel- • Cervical musculo- • Cervical musculo-
etal and tailored senso- skeletal and tailored skeletal and tailored
rimotor as required sensorimotor as sensorimotor as
required required
Abbreviations: BBQ, barbeque; BPPV, benign paroxysmal positional vertigo; CNS, central nervous system; DVA, dynamic visual acuity; ENT, ear-nose-throat
specialist; JPE, joint position error; SPNT, smooth-pursuit neck torsion; VA, vertebral artery; VAD, vertebral artery dissection; VBI, vertebral basilar insufficiency.
*Oculomotor includes skew deviation, vergence, smooth pursuit, and saccades.

IMPLICATIONS FOR onstrated improved dizziness in those would imply that treatment directed to-
MANAGEMENT with whiplash, many continued to have wards improving, for example, eye move-
symptoms of dizziness and signs of bal- ment control may not necessarily be the
G
iven the above and the close ance impairment following the interven- most effective to improve balance or JPS.
connections and adaptations in- tion.123 Similarly, in a study of individuals Thus, a tailored sensorimotor approach
volved in the sensorimotor control with cervicogenic dizziness, while dizzi- with exercises aimed to improve identi-
system, management of these distur- ness improved with manual therapy, fied deficits in cervical joint position and
bances is likely to be multimodal and changes in JPS and balance were neg- movement sense, oculomotor function,
may need to address not only the pri- ligible.85,86 These findings suggest that and static and dynamic balance may be
mary causes but also secondary adaptive additional interventions directed toward superior and is currently recommended
changes in the sensorimotor control sys- these specific other impairments may clinically.55,114,115 A similar combination
tem. It would seem that this should be need to be considered. of cervical musculoskeletal and vestibu-
tailored to the individual and based on lar interventions has been shown to de-
his or her specific self-reports and ob- Addressing Adaptive Changes in crease time to return to sport in young
jective findings (TABLE). Overlap in con- the Sensorimotor Control System adults with persistent symptoms of dizzi-
ventional management approaches may There is some evidence that specific ness, neck pain, and headaches following
therefore occur, for example, making use treatment programs that emphasize gaze concussion.93 Others agree that this com-
of vestibular rehabilitation strategies, but stability, eye-head coordination, and/or bined tailored approach would seem most
again, the management approach is likely head-on-trunk relocation, without in- suitable in those with concussion with
to be more effective if it is a problem-ori- cluding local cervical spine treatment, associated neck trauma.10,30,69 Recently,
ented, tailored, evidence-based approach. have resulted in improvements not only an opinion piece also highlighted the po-
It should also be pointed out that when in sensorimotor impairments but also in tential of vision therapy as a component
neck pain is associated with vestibular neck pain and/or perceived disability in in the management of these patients.6
pathology, often there is a need to ad- those with traumatic neck pain.52,102,116 This area of research is in its infancy and
dress the cervical musculoskeletal im- Vestibular rehabilitation programs have should be considered in future studies.
pairments so that the individual is able been shown to be useful in those with
to effectively complete the exercises for concussion1,45 and resulted in improved CONCLUSION
vestibular rehabilitation, as often this re- balance and dizziness in individuals with
T
quires repetitive fast head/neck motion. WAD.27 Interestingly, in those with WAD, here is considerable evidence
The authors of a recent study have indeed this training did not improve neck pain to support the importance of cer-
demonstrated the benefits of including a or movement.28 Thus, such an approach vical afferent dysfunction in the
musculoskeletal intervention in those provided in isolation may not be able to development of dizziness, unsteadiness,
with peripheral vestibular pathology.131 address all of the deficits or be the most visual disturbances, and altered balance,
efficient approach. eye, and head movement control follow-
Cervical Musculoskeletal Management ing neck trauma, especially in those with
Several studies have demonstrated im- Combined Cervical Musculoskeletal persistent pain. A thorough evaluation is
provements in dizziness and/or senso- Treatment and Structured required to also consider other possible
rimotor control in those with traumatic Sensorimotor Approach causes and secondary adaptive changes
neck pain following treatment only tar- Studies that have included eye-head cou- in the process of differential diagnosis.
geted to the cervical spine, which likely pling and coordination exercises as part It is important that such symptoms and
addressed some of the causes of altered of a multimodal approach have dem- impairments be adequately assessed and
cervical afferent input. Acupuncture has onstrated improvements in neck pain tailored management be implemented.
been shown to improve cervical JPS, and JPS.46,84 A pilot trial of a combined This should become an essential part
dizziness,46 and standing balance,33 and approach demonstrated significant of the routine assessment and man-
improvements in dizziness and JPS have improvements in postural stability in agement of those with traumatic neck
also been demonstrated following man- those with chronic whiplash.75 pain, including those with concomitant
ual therapy.46 Further, cervical muscle injuries such as concussion, vestibular
endurance training improved balance in Combined Cervical Musculoskeletal system damage, and visual pathology or
individuals with whiplash.99 Neverthe- and Tailored Sensorimotor Approach deficits. Ongoing research to assist dif-
less, while a recent clinical trial focusing While a combined approach may be ferential diagnosis and to understand
on specific neck muscle exercises com- more suitable, the lack of direct correla- the most important contributing factors
bined with a behavioral approach dem- tion between sensorimotor measures103,118 associated with abnormal cervical input

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[ clinical commentary ]

JULIA TRELEAVEN, PhD, BPhty1

Dizziness, Unsteadiness, Visual

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after a sport-related concussion: measure- 93. S

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502 | july 2017 | volume 47 | number 7 | journal of orthopaedic & sports physical therapy

Therapies in Clinical Practice 47, 101390. [Crossref]

CONCUSSION HISTORY AND SYMPTOM PRESENTATION IN COMBAT SPORT ATHLETES. Physical

1457:1, 26-40. [Crossref]

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Dev. 2010;47:183-199. https://doi.org/10.1682/ BRS.0000000000001016 67. L’Heureux-Lebeau B, Godbout A, Berbiche D,