Svimmelhed med reference til cervikalcolumna - Hønen eller ægget Evidensbaseret undersøgelse og behandling
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)
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
EFFERENT KOPI MOTOR SIGNAL MISMATCH?
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
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)
Ætiologi WAD (40-80%) Arthritis Spondylose Prolaps Hovedtraume Uhensigtsmæssigt bevægemønster (Wrisley 2000, Heindenreich 2008, Thömke 2007, Reid 2005, Yahia 2009)
Mulige mekanismer Mekanisk blokering af arteria vertebralis Mekanisk kompression af spinalkanalen Irritation af cervikale sympatiske nervesystem Sobotta 160
Påvirkning af proprioceptorer i øvre cervikal columna Neurofysiologiske forhold Eksperimentelle studier Indirekte evidens fra behandling
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)
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)
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)
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
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)
Diagnostiske test Neck Torsion Nystagmus Test Cervical Joint Position Error Svaj / posteografi
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).
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
Behandling Nogle case-rapporter Mangel på kontrollerede kliniske forsøg Lav metodisk kvalitet
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)
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)
Lokalbedøvende injektioner kutant og i periost Multisegmental blokade af somatosensorisk input, samt sympatisk indflydelse på proprio- og nociception!?
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.
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.
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