Head Neck Differentiation Test

What is cervicogenic dizziness?

Cervicogenic dizziness is a type of dizziness that originates from the cervical spine, or neck. It is often associated with neck pain and is thought to be caused by abnormal sensory input from the cervical spine structures, including muscles, joints, and ligaments. This abnormal input can affect the vestibular system, leading to sensations of dizziness or imbalance.

Unlike typical dizziness or benign paroxysmal positional vertigo (BPPV), which are usually caused by issues within the inner ear, cervicogenic dizziness is linked to neck dysfunction. BPPV, for example, causes brief episodes of vertigo triggered by changes in head position, often accompanied by nystagmus (involuntary eye movement). In contrast, cervicogenic dizziness tends to be more persistent and is directly related to neck movement or sustained neck postures.

Cervicogenic dizziness often includes a sense of unsteadiness, lightheadedness, and imbalance, which are typically exacerbated by neck movements or specific head positions. Patients may also experience neck pain, headaches, and a limited range of motion in the neck. Other associated symptoms can include visual disturbances, nausea, and a general feeling of disorientation. These are the same symptoms that provocative tests try to replicate. Unlike BPPV, cervicogenic dizziness does not usually involve nystagmus (involuntary eye movements).

Cervicogenic dizziness can be caused by various conditions affecting the cervical spine, including whiplash injuries, cervical spondylosis, cervical myofascial pain syndrome, and degenerative disc disease. Trauma to the neck, such as from a car accident or sports injury, can also lead to cervicogenic dizziness. Additionally, poor posture, muscle tension, and repetitive neck strain can contribute to the development of this condition.

How to assess for cervicogenic dizziness

Assessing cervicogenic dizziness involves a comprehensive examination that includes various suggested clinical tests. Key assessments include:

• Gaze stability assessment
• Saccadic eye movement assessment
• Eye-head coordination assessment
• Postural stability assessment
• Joint position sense error assessment (also known as the cervical relocation test)
• Smooth pursuit neck torsion test
• Clinical cervical torsion test (also known as the cervical neck torsion test)
• Cervical flexion rotation test

These specific diagnostic tests help in differential diagnosis by isolating the cervical spine as the source of dizziness by evaluating different aspects of eye, head, and body movement and their coordination. A thorough assessment using these tests is needed for accurate clinical diagnosis of cervicogenic dizziness and differentiates it from other types of dizziness and issues.

What is the Head Neck Differentiation Test?

The Head Neck Differentiation Test is a physical examination used to identify cervicogenic dizziness, which is dizziness originating from issues in the cervical spine. The test is characterized by its three components: en bloc rotation, torsion, and rotation. Each component involves distinct movements to isolate cervical spine involvement.

How to perform the Head Neck Differentiation Test

To perform the this clinical test, follow the steps outlined below. The first step involves accessing the template on the Carepatron app.

1. Ensure you have the latest version of the Carepatron app and open the Head Neck Differentiation Test template. You can then fill it out digitally or print it.
2. Seat the patient on a swivel chair with their eyes closed and hips and knees flexed to 90 degrees.
3. Do the en bloc component:
   • The patient actively rotates their trunk with the help of their legs to the left and right side for 45° at a metronome pace of 60 beats per minute.
   • Head and trunk rotation should go on for about 30 seconds.
   • Let the patient open their eyes. Observe for symptoms and record any. Terminate the test and mark it positive if the patient cannot continue.
4. Do the torsion component:
   • If the patient can continue, have them close their eyes again.
   • Repeat the same movement as in the En bloc component for 30 seconds, but this time, hold the patient’s head still while their trunk rotates.
   • Let the patient open their eyes. Observe for symptoms and record any. Terminate the test and mark it positive if the patient cannot continue.
5. Do the rotation component:
   • If the patient can continue, have them keep their eyes closed.
   • This time, the patient starts cervical rotation, moving their head to the left and right side for 45° at a metronome pace of 90 beats per minute while the trunk remains stationary for 30 seconds.
   • Terminate the test if the patient experiences any symptoms.

Results and interpretation of the Head Neck Differentiation Test

The examiner must use their judgment to determine normative responses. The test is considered positive if the patient reports any of the following symptoms during or immediately after any component of the test:

• Dizziness
• Visual disturbances
• Unusual eye movements after opening the eyes
• Speech disturbance
• Motion sickness or nausea
• Slurred speech
• Dysphagia
• Light-headedness
• Tinnitus
• Headache
• Paresthesia

A positive test suggests a cervicogenic origin of the dizziness, especially if symptoms are observed during the torsion component, which isolates cervical afferent stimulation. The en bloc component isolates vestibular stimulation while the rotation component includes both vestibular and cervical, so if symptoms are observed only during these components, other causes of dizziness may need to be considered.

What are the next steps?

If the Head Neck Differentiation Test is positive, further assessments should be conducted to confirm the diagnosis and develop an appropriate treatment plan. These assessments may include gaze stability, saccadic eye movement, eye-head coordination, postural stability, joint position sense error, smooth pursuit neck torsion, cervical torsion, and cervical flexion rotation tests. This comprehensive approach ensures accurate diagnosis and effective management of cervicogenic dizziness.