Dizziness After Concussion: A Case for Cervicogenic Dizziness

by Jonathan Chung, DC

Persistent dizziness and imbalance is a common feature for patients diagnosed with post-concussion syndrome. This is often a difficult symptom to treat medically because dizziness comes in many different forms and can be caused by injuries or illnesses to different parts of the body:

• A feeling of spinning vertigo can be related to crystals being dislodged from the inner ear
• Feeling lightheadedness may be a blood flow issue into the brain from dysautonomia or heart problems
• Feelings of nausea and anxiousness with moving visual scenes and backgrounds can indicate a problem with your eyes and visual system

Contrary to popular belief, many patients who have endured a concussion don’t have the spinning feeling of vertigo beyond the day of the initial injury. When it comes to persistent dizziness after concussion, one of the most common presentations is generally a sense of being unsteady and off balance while standing and walking. Many patients will describe the symptom that we call disequilibrium  as a feeling of “being off,” and they are reluctant to move without the help of a wall, cane, or a loved one’s arm for support.

The feeling of disequilibrium can be felt across a wide range of  patients. Positional vertigo or chronic vestibular nerve injury can be affected by disequilibrium as well in the immediate aftermath of a concussion. However, if you have gone to a doctor and the tests for your inner ear are clear and the normal time frame for an acute concussion has passed, there’s a strong likelihood that the feelings of dizziness are cervicogenic, or coming from the neck.

“Why Doesn’t My Doctor Consider Cervicogenic Dizziness?”

Cervicogenic dizziness has a controversial history, and many ENTs and neurologists still say that it doesn’t exist. The reason many doctors say it doesn’t exist is because, historically, there was no good way to diagnose cervical dizziness.

Most cases of dizziness or vertigo are diagnosed by using specialized tests of the inner ear or brain such as caloric testing, vestibulo-oculography, posturography, rotational chair testing, or vestibular evoked potentials. These tests are sensitive to any loss of function from the vestibular organs inside your inner ear that provide your sense of balance and equilibrium.

When dizzy patients don’t have measurable signs of inner ear dysfunction, eye disorders, brain disease, or tumors, there’s a tendency to dismiss the patient’s complaints as psychogenic, but some doctors and chiropractors find that treating the neck resolves a patients complaint.

While this is great for a patient, it’s not great for creating a diagnosis. Naming a diagnosis based on a response to treatment doesn’t really work scientifically.

Cervical Dizziness and Trauma

One place that really helped make cervicogenic dizziness a more legitimate entity is the emergence of research on head and neck trauma. Studies on motor vehicle accidents showed that many patients who suffer whiplash often had disequilibrium without any inner ear pathology.

The muscles, joints, and ligaments of the upper neck provide really important sensory information to the brainstem and cerebellum that play important roles in helping to maintain balance and equilibrium. This occurs through a sense called proprioception, the sense of knowing where your joints are in space.

The upper neck, from C1-C3, is really unique in that it provides significant proprioceptive feedback to the brain, more than the rest of the spine. The theory is that the neck joints and muscles provide information about your head movement; this information is compared to the signals that are being sent from the vestibular organs in your ears and visual signals in your eyes.

When the signals among the inner ear, neck, and eyes disagree, it creates a sensory conflict that your brain has to resolve. When it can’t resolve it effectively, you will feel dizzy, off balance, or nauseated.

The upper neck is one of the most mobile joints in the entire body.   The cost of high mobility means that joints in the upper neck are quite prone to injury and instability from high impact forces. The upper neck is susceptible to sprains, strains, and misalignments from blows to the head or a really aggressive acceleration from whiplash.

When you injure these joints, the feedback your brain needs from your neck gets disrupted, which increases your odds of having sensory conflict that will lead to you feeling poorly.

How Do I know If I Have This?

There’s still no gold standard test to diagnose cervicogenic dizziness, but whiplash research has given us some tools to determine if a neck injury is influencing your symptoms.

A physiotherapist or chiropractor trained in cervical and vestibular rehabilitation may be able to perform the following tests if you have dizziness.

• Smooth Pursuit Neck Torsion Test – a test looking at the smoothness of your eye movements while your body is turned and your head is kept straight.
• Cervical Joint Position Error – A test performed with a head laser where your head is placed in neutral, the head is moved to a turned position and the patient returns it back to the neutral position. The amount of error is recorded over several trials.

Abnormalities in one or both of these tests have shown to be more prevalent in patients with dizziness following whiplash compared to patients with no dizziness complaint.

Once your know that your neck is the problem, a well-trained physiotherapist or chiropractor can help restore normal movement and sensation from the neck, and the results can sometimes be fast and dramatic.

Jonathan Chung, DC is the founder and upper cervical chiropractor at Keystone Chiropractic and Neuroplasticity in Wellington, Florida. Learn more about their cervical vestibular rehabilitation program at www.chiropractickeystone.com