Cervikogen svimmelhed. Svimmelhed med reference til cervikalcolumna - Hønen eller ægget. Evidensbaseret undersøgelse og behandling

Transkript

1 Svimmelhed med reference til cervikalcolumna - Hønen eller ægget Evidensbaseret undersøgelse og behandling

2 Definitioner Cervicogenic dizziness is dizziness attributed to involment of the cervical spine (Biesinger 1988) A non-specific sensation of altered orientation in space and dysequilibrium originating from abnormal afferent activity from the neck (Wrisley 2000)

3 Svimmelhed Følelse af spatial desorientering, bevægelse af omgivelserne eller instabilitet. Vertigo: Subjektiv fornemmelse af at dreje rundt eller svaje på trods af, at kroppen er stationær i forhold til omgivelserne. Presynkope: Fornemmelse af at være ved at besvime Instabilitet (dysequilibrium): Kan være subjektiv eller objektiv Ukarakteristisk

4 EFFERENT KOPI MOTOR SIGNAL MISMATCH?

5 Vertigo Presyncope Dysequilibrium Ukarakteristisk Benign paroxysmal positional vertigo Menière s disease Acute peripheral vestibulopathy Otosclerosis Head trauma Cerebellopontine angle tumor Toxic vestibulopathies Acoustic neuropathy Perilymphatic fistula Autoimmune disease of the inner Cerebellar drug intoxication Wernicke s encephalopathy Inflammatory cerebellar disorders Multiple sclerosis Alcoholic cerebellar degeneration Phenytoin-induced cerebellar degeneration Hypothyroidism Paraneoplastic cerebellar degeneration Hereditary spinocerebellar degenerations Ataxia-telangiectasia Wilson s disease Creutzfeldt-Jakob disease Posterior fossa tumors Posterior fossa malformations Familial paroxysmal ataxia Vasovagal presyncope Cardiovascular presyncope Migraine Takayasu s disease Carotid sinus syndrome Orthostatic hypotension Hyperventilation Cough-related syncope Micturition syncope Glossopharyngeal neuralgia Hypoglycemia Vertebrobasilar insufficiency Vertebrobasilar infarction Vertebrobasilar migraine Subclavian steal syndrome Visual impairment Myelopathy Musculoskeletal impairment Basal ganglia impairment Panic disorder Phobic postural vertigo Otolith dysfunction

6 Symptomer og fund Smerte og ubehag i cervikalregionen Svimmelhed af kort varighed Svimmelhed påvirkes af bestemte hovedpositioner og bevægelser Nedsat balance og gangdeviationer Occipital hovedpine Kæbesmerter Radikulære symptomer for OE Cervikal bevægelighed? (Biesinger 1988, Wrisley 2000, Malmström 2006, Yahia 2009)

7 Ætiologi WAD (40-80%) Arthritis Spondylose Prolaps Hovedtraume Uhensigtsmæssigt bevægemønster (Wrisley 2000, Heindenreich 2008, Thömke 2007, Reid 2005, Yahia 2009)

8 Mulige mekanismer Mekanisk blokering af arteria vertebralis Mekanisk kompression af spinalkanalen Irritation af cervikale sympatiske nervesystem Sobotta 160

9 Påvirkning af proprioceptorer i øvre cervikal columna Neurofysiologiske forhold Eksperimentelle studier Indirekte evidens fra behandling

10 Neurofysiologiske forhold Facetled og paraspinale ligamenter indeholder mekanoreceptorer med forbindelse til vestibulære, cervikale, spinale og øjenmotoriske kerner, samt cerebellum og thalamus Cervikal muskulatur indeholder muskeltene, hvis afferens indgår i vigtige posturale og oculomotoriske reflekser (McLain 1994, Morningstar 2005, Armstrong 2008)

11 Eksperimentelle studier Lokalbedøvelse i nakkemuskulaturen kan fremkalde nystagmus, ataxi, og følelse af lateropulsation mod den påvirkede side (de Jong 1977) Unilateral vibration af nakkemuskler kan fremkalde ipsilateral deviation af lige frem og nystagmus (Biguer 1988, Popov 1999, Karnath 2002)

12 Eksperimentelle studier Vestibulære neuroner er sensitive for passiv cervikalrotation (Gdowski 2000) Cortikale områder som aktiveres af vestibulære signaler aktiveres også af proprioceptive signaler (Bottini 2001) Cervikal proprioceptionen kompenserer for vestibulært tab (Strupp 1998 og 1999, Schweigart 2002) - men patient uden cervikal proprioception overvurderer helkropsrotation i mørke på trods af normal vestibulær funktion (Blouin 1995)

13 CNS Kortikal repræsentation Somatisk reorganisering Visuelle system Ændret refleks Ændret cervikal afferens Ændret refleks Vestibulære system Trauma Iskæmi Inflammation Nedsat neuromuskulær kontrol Morfologiske forandringer Ændret mekanoreceptor aktivitet Smerte Sympaticus aktivering Ændret muskeltene aktivitet

14 Diagnostik og undersøgelse Diagnosis of exclusion 1. Tæt temporal sammenhæng mellem cervikal smerte og svimmelhedssymptomer. Både mht. opståen og hyppigheden af symptomer. 2. Kendt cervikal skade eller patologi. 3. Andre mulige forklaringer er udelukket. (Wrisley 2000)

15 Diagnostiske test Neck Torsion Nystagmus Test Cervical Joint Position Error Svaj / posteografi

16 Smooth Persuit Neck Torsion Test Patienten følger et visuelt signal. Først i neutralposition - derefter med hovedet roteret Klassificerer WAD-patienter med svimmelhed i forhold til raske: Sensitivitet: 90% og specificitet: 91% (Tjell og Rosenhall 1998) Også WAD-patienter uden svimmelhed har positiv SPNT (Treleaven 2005, 2008).

17 Undersøgelse klinisk Udelukkelse af andre årsager Anamnese (Vertigo?) Symptomer og Neurologisk screening øjenbevægelser Test for VBI i siddende Helkropsrotationer Isoleret torsobevægelse / positionering Postural stabilitet Manuel undersøgelse af øvre kvadrant

18 Behandling Nogle case-rapporter Mangel på kontrollerede kliniske forsøg Lav metodisk kvalitet

19

20 This systematic review has found that there is limited evidence at present to support the use of manual therapy in treating cervicogenic dizziness (Reid 2003)

21 SNAGs eller slukket laser 4-6 behandlinger i 4 uger SNAGs Mindre svimmelhed og smerter, samt forøget cervikal bevægelighed Ingen ændring for placebogruppen 12 mdr. FU: Ingen statistisk forskel mellem grupperne (Reid 2006)

22

23 Lokalbedøvende injektioner kutant og i periost Multisegmental blokade af somatosensorisk input, samt sympatisk indflydelse på proprio- og nociception!?

24 Konklusion Præcis cervikal afferens er nødvendig for postoral kontrol og korrekt perception af position og bevægelse. Perceptionen af position og bevægelse kan påvirkes gennem manipulation af cervikal afferens. Patienter med cervikale dysfunktioner og svimmelhed, hvor andre grunde til svimmelheden er udelukket, kan behandles for svimmelheden gennem behandling af den cervikale dysfunktion. Der er tegn på, at der findes en sammenhæng mellem cervical smerte og svimmelhed.

25 Betydningen for kliniske praksis Hos patienter med svimmelhed skal andre årsager udelukkes før cervikogen svimmelhed diagnosticeres. Hos patienter med svimmelhed af andre primære årsager kan ændret cervikal afferens eller cervikal repræsentation i CNS være ansvarlig for en væsentlig del af symptombilledet. Svimmelhed kan behandles gennem forskellige fysioterapeutiske tilgange, men strategier for vedligeholdelse af effekten synes at være væsentlig.

26 Referencer: Alund M, Ledin T, Odkvist L, Larsson SE. Dynamic posturography among patients with common neck disorders. A study of 15 cases with suspected cervical vertigo. J Vestib Res Winter;3(4): Armstrong B, McNair P, Taylor D. Head and neck position sense. Sports Med. 2008;38(2): Benito-León J, Díaz-Guzmán J, Madero S, Rivas JJ, Rabasa M, RodríguezVallejo A. Vertigo as an atypical symptom of intraspinal cord tumor Rev Neurol May;24(129): Biesinger E. Vertigo caused by disorders of the cervical vertebral column. Diagnosis and treatment. Adv Otorhinolaryngol. 1988;39: Biguer B, Donaldson IM, Hein A, Jeannerod M. Neck muscle vibration modifies the representation of visual motion and direction in man. Brain Dec;111 ( Pt 6): Blouin J, Vercher JL, Gauthier GM, Paillard J, Bard C, Lamarre Y. Perception of passive whole-body rotations in the absence of neck and body proprioception. J Neurophysiol Nov;74(5): Bottini G, Karnath HO, Vallar G, Sterzi R, Frith CD, Frackowiak RS, Paulesu E. Cerebral representations for egocentric space: Functional-anatomical evidence from caloric vestibular stimulation and neck vibration. Brain Jun;124(Pt 6): Brandt T. Cervical vertigo--reality or fiction? Audiol Neurootol Jul-Aug;1(4): Brandt T, Bronstein AM. Cervical vertigo. J Neurol Neurosurg Psychiatry Jul;71(1):8-12. de Jong PT, de Jong JM, Cohen B, Jongkees LB. Ataxia and nystagmus induced by injection of local anesthetics in the Neck. Ann Neurol Mar;1(3): Heidenreich KD, Beaudoin K, White JA. Cervicogenic dizziness as a cause of vertigo while swimming: an unusual case report. Am J Otolaryngol Nov-Dec;29(6): Heikkilä H, Johansson M, Wenngren BI. Effects of acupuncture, cervical manipulation and NSAID therapy on dizziness and impaired head repositioning of suspected cervical origin: a pilot study. Man Ther Aug;5(3): Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B. Retraining cervical joint position sense: the effect of two exercise regimes. J Orthop Res Mar;25(3): Karlberg M, Johansson R, Magnusson M, Fransson PA. Dizziness of suspected cervical origin distinguished by posturographic assessment of human postural dynamics. J Vestib Res Jan-Feb;6(1): Karlberg M, Magnusson M, Malmström EM, Melander A, Moritz U. Postural and symptomatic improvement after physiotherapy in patients with dizziness of suspected cervical origin. Arch Phys Med Rehabil Sep;77(9): Karnath HO, Reich E, Rorden C, Fetter M, Driver J. The perception of body orientation after neck-proprioceptive stimulation. Effects of time and of visual cueing. Exp Brain Res Apr;143(3): Kristjansson E, Dall'Alba P, Jull G. Cervicocephalic kinaesthesia: reliability of a new test approach. Physiother Res Int. 2001;6(4): McLain RF. Mechanoreceptor endings in human cervical facet joints. Spine (Phila Pa 1976) Mar 1;19(5): Michels T, Lehmann N, Moebus S. Cervical vertigo--cervical pain: an alternative and efficient treatment. J Altern Complement Med Jun;13(5): Mitchell J. Is mechanical deformation of the suboccipital vertebral artery during cervical spine rotation responsible for vertebrobasilar insufficiency? Physiother Res Int Mar;13(1): Mitchell J, Keene D, Dyson C, Harvey L, Pruvey C, Phillips R. Is cervical spine rotation, as used in the standard vertebrobasilar insufficiency test, associated with a measureable change in intracranial vertebral artery blood flow? Man Ther Nov;9(4): Morningstar MW, Pettibon BR, Schlappi H, Schlappi M, Ireland TV. Reflex control of the spine and posture: a review of the literature from a chiropractic perspective. Chiropr Osteopat Aug 9;13:16.

27 Oosterveld WJ, Kortschot HW, Kingma GG, de Jong HA, Saatci MR. Electronystagmographic findings following cervical whiplash injuries. Acta Otolaryngol. 1991;111(2): Padoan S, Karlberg M, Fransson PA, Magnusson M. Passive sustained turning of the head induces asymmetric gain of the vestibulo-ocular reflex in healthy subjects. Acta Otolaryngol Nov;118(6): Popov KE, Lekhel H, Faldon M, Bronstein AM, Gresty MA. Visual and oculomotor responses induced by neck vibration in normal subjects and labyrinthine-defective patients. Exp Brain Res Oct;128(3): Reid SA, Rivett DA. Manual therapy treatment of cervicogenic dizziness: a systematic review. Man Ther Feb;10(1):4-13. Reid SA, Rivett DA, Katekar MG, Callister R. Sustained natural apophyseal glides (SNAGs) are an effective treatment for cervicogenic dizziness. Man Ther Aug;13(4): Revel M, Andre-Deshays C, Minguet M. Cervicocephalic kinesthetic sensibility in patients with cervical pain. Arch Phys Med Rehabil Apr;72(5): Ron Schenk, laura Coons Susan Bennet, Peter Huijbregts Cervicogenic Dizziness: A case Report Illustrating Orthopaedic Manual and Vestibular Physical Therapy Comanagement The Journal of Manual & Manipulative Therapy Vol. 14 No. 3(2006) Schweigart G, Chien RD, Mergner T. Neck proprioception compensates for age-related deterioration of vestibular self-motion perception. Exp Brain Res Nov;147(1): Strupp M, Arbusow V, Borges Pereira C, Dieterich M, Brandt T. Subjective straight-ahead during neck muscle vibration: effects of ageing. Neuroreport Oct 19;10(15): Strupp M, Arbusow V, Dieterich M, Sautier W, Brandt T. Perceptual and oculomotor effects of neck muscle vibration in vestibular neuritis. Ipsilateral somatosensory substitution of vestibular function. Brain Apr;121 ( Pt 4): Thömke F. Frequently occurring forms of dizziness and their treatment MMW Fortschr Med May 21;149 Tjell C, Rosenhall U. Smooth pursuit neck torsion test: a specific test for cervical dizziness. Am J Otol Jan;19(1): Treleaven J, Jull G, LowChoy N. Smooth pursuit neck torsion test in whiplash-associated disorders: relationship to self-reports of neck pain and disability, dizziness and anxiety. J Rehabil Med Jul;37(4): Treleaven J, Jull G, Lowchoy N. Standing balance in persistent whiplash: a comparison between subjects with and without dizziness. J Rehabil Med Jul;37(4): Treleaven J, LowChoy N, Darnell R, Panizza B, Brown-Rothwell D, Jull G. Comparison of sensorimotor disturbance between subjects with persistent whiplash-associated disorder and subjects with vestibular pathology associated with acoustic neuroma. Arch Phys Med Rehabil Mar;89(3): Treleaven J, Jull G, Sterling M. Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error. J Rehabil Med Jan;35(1): Wrisley DM, Sparto PJ, Whitney SL, Furman JM. Cervicogenic dizziness: a review of diagnosis and treatment. J Orthop Sports Phys Ther Dec;30(12): Yahia A, Ghroubi S, Jribi S, Mâlla J, Baklouti S, Ghorbel A, Elleuch MH. Chronic neck pain and vertigo: Is a true balance disorder present? Ann Phys Rehabil Med Sep-Oct;52(7-8):