Seated cervical flexion-rotation test equivalent to supine for identifying cervical dysfunction in patients with dizziness/vertigo

Abstract

BACKGROUND:

The upper cervical spine should be assessed in patients with complaints of dizziness or vertigo [1 –3]. The supine cervical flexion-rotation test (SupCFRT) reliably assesses for the presence of upper cervical spine dysfunction (UCSD) [4]. UCSD has been linked to symptoms often seen in those diagnosed with dizziness or vertigo. Patients diagnosed with dizziness/vertigo often do not tolerate the supine testing position necessary to perform the SupCFRT, but often tolerate sitting well.

PURPOSE:

To determine if UCSD can be assessed in sitting as reliably as in supine.

METHODS:

Forty-five college age students (23.7±3.3 years old) acted as controls while forty-six subjects (56.71±14.6 years old) who were referred for physical therapy services by their medical provider acted as the patient group. The SupCFRT was performed first, [4] the Seated Cervical Flexion-Rotation Test (SeatCFRT) was performed next by positioning the subjects seated with their back against a high-backed chair, the head was flexed maximally, then rotated maximally left and right. The SupCFRT [4] and SeatCFRT were considered positive if range of motion limitations were found. Results for each test was compared using McNamar X².

RESULTS:

There was no difference, p > 0.05, between SupCFRT and SeatCFRT for all conditions; all subjects (n = 91), control subjects n = 45, subjects referred to physical therapy for treatment of dizziness or vertigo, n = 46.

DISCUSSION:

The SeatCFRT reliably identifies the presence of UCSD, in controls and patients diagnosed by a referring medical provider for dizziness or vertigo. Patients, who do not tolerate the supine position, can be evaluated for UCSD in the seated position.

Keywords

Cervicogenic dizziness cervicogenic vertigo upper cervical spine cervical flexion rotation test benign paroxysmal positional vertigo

1 Introduction

Vertigo and dizziness are common problems frequently addressed by physical therapists in the adult population [1–3 , 6]. While vertigo and dizziness are most often associated with the inner ear, symptoms associated with vertigo and dizziness have been shown to be caused by, or exist in combination with, upper cervical spine dysfunction (UCSD) [1–3 , 6]. UCSDs, which have been associated with symptoms consistent with those diagnosed with vertigo and/or dizziness include; muscle spasm in the deep rotators and extensors attaching to the upper cervical spine from the occiput to C4, joint mobility restrictions as well as degenerative changes within the zygapophyseal joints. [1–3 , 5–7]. While most often associated with complaints of pain in the upper cervical spine or posterior neck and head, pain does not always have to be present for upper cervical spine dysfunction to be causing vertigo and dizziness-like symptoms. This dysfunction in the absence of pain may be due to aberrant firing of the upper cervical mechanoreceptors rather than just simple firing of pain receptors [1, 2]. This is critically important when one realizes that mechanoreceptors located with joints extending from C1 to C3 represent half of the proprioceptive input to the brain [1].

Screening for the presence of UCSD is therefore highly recommended for primary care providers, neurologists, vestibular specialists and physical therapist who are evaluating patient with complaints of vertigo and/or dizziness. The most common non-invasive special test readily available to the physical therapist, which is also recommended as part of the screening process for those with neck pain/dysfunction, is the supine cervical flexion-rotation test (SupCFRT) [4]. The (SupCFRT) is widely used in manual/orthopedic physical therapy, but may be underutilized by those working with patients diagnosed with vertigo or dizziness. The SupCFRT is considered a valid and reliable gold-standard test used in the assessment of the upper cervical spine by osteopaths and orthopedic physical therapists for a wide variety of conditions including concussion, post-concussion syndrome, headache, cervicogenic vertigo, cervicogenic dizziness and cervicogenic headache [4 , 8–11]. Unfortunately, as the name implies, the test requires the patient to be positioned in supine. The supine position often exacerbates symptoms of vertigo and dizziness. This often makes in difficult or uncomfortable for patients to assume the supine position for testing purposes [12]. Finding a more tolerable testing position in which to assess the mobility of the upper cervical spine in patients with vertigo or dizziness who cannot tolerate assuming the supine position inherent with the SupCFRT would be very beneficial for clinicians wishing to assess the upper cervical spine more comfortably for their patients. The seated position is well tolerated by those with vertigo and dizziness. The investigators felt that measuring cervical rotation with the head maximally flexed while in the seated position would allow for a weighted assessment of upper cervical mobility in patients with vertigo or dizziness. In the seated position the weight of the cranium is borne on the articular pillars of the atlas which in turn bears weight on the axis and so on. Anatomically, this arrangement more closely mimics the osteokinematic motion seen during activities of daily living often associated with dizziness and vertigo [1, 2]. The objective/purpose of this study was to compare results of the seated cervical flexion-rotation test (SeatCFRT) with the gold-standard SupCFRT in both controls and those who were referred, by a medical provider, to physical therapy with a diagnosis of concussion, benign paroxysmal positional vertigo (BPPV), vertigo or dizziness. We hypothesized that performing the SeatCFRT would yield equivalent results as that of the gold standard SupCFRT in all subjects, controls as well as those diagnosed and referred for physical therapy services for treatment of concussion, BPPV, vertigo or dizziness.

2 Methods

Prior to data collection all subjects read and signed the appropriate informed consent documents approved by the University’s institutional review board. All procedures followed during the study were in accordance with the Helsinki Declaration of 1975, as revised in 1983. All subjects were recruited using print and digital posters, flyers and word of mouth at the University and hospital facility in which the study was performed. Data from forty-five college age students, without history of neck pain, BPPV, dizziness or vertigo volunteered to act as controls in this study. Forty-six subjects who had been referred to physical therapy for services by a referring medical provider for evaluation and treatment of concussion, BPPV, vertigo or dizziness volunteered to enroll in the study, increasing the total sample to ninety-one subjects. Inclusion criteria for both the control and patient groups included being 18 years of age or older, with no history of cervical surgery/fracture, stroke seizures, neurologic condition or traumatic brain injury (as identified by imaging). The forty-six patients who volunteered to become subjects also had to be referred for physical therapy services by a physician, physician’s assistant or nurse practitioner for vertigo, dizziness, BPPV or concussion. The electronic medical record for these forty-six patients was also scanned for conditions listed previously. Lastly prior to data collection, all subjects had to demonstrate a negative Sharp Purser and Spurling’s tests, as described by Dutton [13].

All subjects, n = 91, were tested in the following order SeatCFRT followed by SupCFRT. All testing was performed by the same examiner who was not blinded to testing condition. This order was maintained in order to avoid repeated repositioning of the subject and to save time during their evaluation. Researchers were concerned that frequent repositioning necessary for randomization would exacerbating the subject’s/patient’s symptoms [12]. A fixed order of testing designed to employ multiple test in the same position reduced time required for testing given that these subjects/patients were part of a larger study and were being tested as part of a comprehensive physical therapy examination in a clinical environment. This reduced the burden of extra time on the facility, the clinician performing the tests as well as the time spent in the evaluation process for the patient. The SupCFRT was performed in supine by first passively flexing the head maximally towards the chest and then rotating the head maximally to the left and then to the right, as previously described [4 , 15]. The SeatCFRT was performed in a similar manner as the supine version only the subject was positioned in a high-backed chair with their back supported. The head was maximally flexed downward to the chest then rotated left and then right. Unilateral or bilateral restrictions in range of motion observed during SeatCFRT were classified using the same system as described for the SupCFRT and if positive were indicative of upper cervical dysfunction [4 , 16]. The data for both the SupCFRT and the SeatCFRT was converted into either positive, presence of limited range of motion, or negative no detectable limitation, in a similar manner as a treating physical therapist would do in order to assess for the presence of UCSD in a real patient. The dichotomous, nonparametric data was then analyzed using both the corrected and noncorrected formulas for McNemar X². All analyses were performed using SPSS (version 26, IBM Armonk, NY).

3 Results

Ninety-one subjects entered and completed this study, there were no lost data points nor adverse effects noted or reported. The forty-five college age students (23.7±3.3 years old) acted as controls. The forty-six subjects (56.71±14.6 years old) were referred to physical therapy for treatment of concussion (n = 3), dizziness (n = 9), vertigo (n = 28) or BPPV (n = 6) also took part in the study. None of the forty-six subjects referred to physical therapy were thought to have cervical involvement by their referring medical provider at the time of referral, however 56.5% of them exhibiting a positive SupCFRT, indicating the presence of UCSD, see Table 1.

Table 1
Count and percentage with Positive Supine Cervical Flexion Rotation tests

Referring diagnosis Negative SupCFRT (%) Positive SupCFRT (%) Subtotal

BPPV 4 (66.7%) 2 (33.3%) 6

Vertigo 11 (39.3%) 17 (60.7%) 28

Dizziness 4 (44.4%) 5 (55.6%) 9

Concussion 1 (33.3%) 2 (66.7%) 3

Total 20 (43.5%) 26 (56.5%) 46

Referring diagnosis	Negative SupCFRT (%)	Positive SupCFRT (%)	Subtotal
BPPV	4 (66.7%)	2 (33.3%)	6
Vertigo	11 (39.3%)	17 (60.7%)	28
Dizziness	4 (44.4%)	5 (55.6%)	9
Concussion	1 (33.3%)	2 (66.7%)	3
Total	20 (43.5%)	26 (56.5%)	46

Data from Tables 2&3 were utilized to calculate the corrected and uncorrected McNemar X² Statistic and corresponding p values, see Tables 4&5, as recommended by Newcombe⁵ utilizing a macro for SPSS and available from http://www.how2stats.net/2011/09/two-proportions-test-related-spss.html (accessed 10/22/19).

Table 2

2 x 2 Table for seated and supine Flexion Rotations Tests in patients referred for Physical Therapy for Dizziness, Vertigo or BPPV, n = 45

			Seated Flexion Rotation Test
			Negative	Positive	Total
Supine Flexion Rotation Test	Negative	Count	18	2	20
		% seated FRT positive	100%	7.1%	43.5%
	Positive	Count	0	26	26
		% within Seated FRT	0%	92.9%	56.5%
Total		Count	18	28	46
		% within Supine FRT	39.1%	60.9%	100%

Table 3

2 x 2 Table for Seated and Supine Flexion Rotations Tests in Patients and Controls, n = 91

			Seated Flexion Rotation Test
			Negative	Positive	Total
Supine Flexion Rotation Test	Negative	Count	57	3	60
		% seated FRT positive	98.3%	9.1%	65.9%
	Positive	Count	1	30	31
		% within Seated FRT	1.7%	90.9%	34.1%
Total		Count	58	32	90
		% within Supine FRT	63.7%	36.3%	100%

Table 4

McNemar X² Statistic for patients referred for Physical Therapy for Dizziness, Vertigo or BPPV, n = 45

Test	X ²	Significance
Uncorrected	2.0	0.1573
Corrected	0.50	0.4795

Table 5

McNemar X² Statistic for in Patients and Controls, n = 91

Test	X ²	Significance
Uncorrected	1.0	0.3173
Corrected	0.25	0.6171

When comparing positives for Supine and Seated Flexion Rotation Tests data for only those referred for physical therapy, n = 46, are 56.52%, 60.87% with a difference of –4.35% and a 95% confidence interval (–11.41% –2.82%).

A comparison of positives for Supine and Seated Flexion Rotation Tests Data from all 91 subjects (controls plus those referred to physical therapy) are 34.07%, 36.26% with a difference of –2.20%, 95% confidence interval (–7.06%, 2.64%).

4 Discussion

The upper cervical spine is a causative factor for symptoms associated with the diagnoses of dizziness, vertigo and BPPV [1 –3]. The SupCFRT is considered a reliable and valid gold standard for assessing for the presence of UCSD by physical therapists working in the clinical setting [4 , 15]. The test is typically easy to administer but may be difficult or even impossible to perform on those patients who cannot assume or remain in the supine position long enough to allow for testing to take place. This may pose a significant issue for those who wish to determine whether there is upper cervical involvement/dysfunction in patients diagnosed with or referred for treatment of BPPV, vertigo, dizziness, concussion and post-concussion syndrome who often do not tolerate the supine testing position. The goal of this research study was to attempt to identify an alternate testing procedure, which would be as reliable as the SupCFRT to assess for the presence of UCSD.

The SeatCFRT appears to reliably identify upper cervical spine dysfunction when compared to the SupCFRT in both healthy controls and those previously diagnosed and referred to physical therapy for treatment of BPPV, vertigo, dizziness, concussion and post-concussion syndrome. The results of this study indicate that SeatCFRT offers physical therapists and other medical professionals an alternate way to reliably access the upper cervical spine for the presences of UCSD in patients who do not tolerate the supine position.

The SeatCFRT may also offer physicians and other medical personnel, who may not have the space or equipment to allow the patient to assume the supine testing position or who do not have the time to assist their patients into and out of the supine position, a convenient way to assess for the presence of UCSD. The authors hope that the ease of performing the SeatCFRT may also allow/encourage referring providers the opportunity to test for and identify UCSD in their patients. This may enhance the referring medical provider’s ability to quickly identify USCSD in their patients, improving their diagnostic accuracy, and improving the timeliness for referral to physical therapy for treatment of those whose symptoms may be coming from their neck.

Perhaps had the SeatCFRT been available to the referring providers they may have been able to identify the presence of UCSD in 56.5% of subjects in this study who had been referred to physical therapy for evaluation and treatment of BPPV, vertigo, dizziness, concussion and post-concussion syndrome despite showing clear signs of UCSD. Clearly the findings of this study suggest that further education as to how to screen for UCSD be provided to referring medical providers so that they can more accurately diagnose the potential causation of their patients’ symptoms/pathology. Similarly, it reinforces the need for physical therapists to assess for the presence of UCSD in patients referred to them by medical providers for treatment of vertigo, dizziness, concussion and BPPV.

While there is ample evidence in the literature as to the existence of cervicogenic dizziness/vertigo, [1, 2] this is the first study to report its prevalence using the gold standard test utilized by manual physical therapist to assess the upper cervical spine for dysfunction. This study revealed that UCSD was found in 60.7% of those referred to physical therapy for treatment of vertigo, 55.6% for dizziness, 66.7% for concussion and 33.3% for BPPV. The prevalence of upper cervical dysfunction seen in this study for those diagnosed with concussion is slightly lower 66.7% compared to previous findings 71% [18]. This small difference may in fact be caused by the low number of subjects, n = 3, in this study suffering from concussions. The authors are currently engaged in a much larger prospective study investigating the prevalence of upper cervical spine dysfunction in patients with vertigo, dizziness, BPPV, concussion and post-concussion syndrome.

The authors believe that categorizing SupCFRT and SeatCFRT dichotomously more closely resembles how physical therapists working with patients would identify the presence of upper cervical dysfunction, i.e. it is either present or it is not. This approach is consistent with current recommendations within the literature which would suggest that if upper cervical dysfunction is present it must be treated [4].

The dichotomous data created by performing the SeatedCFRT and the gold standard SupCFRT was analyzed using both the corrected and uncorrected McNemar X² statistic as recommended by Newcombe [17]. The literature reports some controversy as to whether the SPSS calculation is too conservative in its determination of the p value [17]. We included both uncorrected and corrected X² values and their corresponding p values. In both cases the p values exceeded 0.05 indicating that there is no statistically significant difference between the results of SupCFRT and the SeatCFRT using either calculation. Our analysis indicates that the SeatCFRT produces similar results, as compared to the SupCFRT, when identifying the presence of UCSD in patients referred to physical therapy with BPPV, vertigo, dizziness and concussion.

This is the first study to describe the reliability of the SeatCFRT compared to the SupCFRT as well as the prevalence of UCSD in patients diagnosed with BPPV, vertigo and dizziness. Additional studies are currently underway to further explore the value of these two tests.

5 Clinical relevance

Clinicians familiar with performing the SupCFRT can perform the SeatCFRT on patients in order to assess for the presence of UCSD. The SeatCFRT is easily performed in the clinic and does not require patient repositioning. This may make it the preferred testing position for those treating patients with dizziness, vertigo or BPPV, especially when those patients do not tolerate the supine position.

6 Limitations

Due to the nature of patient care and the need to maintain a relationship between the investigators and the patients volunteering to be subjects no blinding was utilized in this study. Testing was performed in the order described above. This was done to reduce time needed for collecting data during the evaluation of the subjects/patients. This also reduced the number of times the subjects/patients were asked to change position during the evaluation. Reducing the number of times, the subjects/patients change positions was deemed important, clinically, as it mitigated the risk of symptom exacerbation in patient/subjects.

The data collectors were not aware (blinded) of the primary author’s intent to compare SeatCFRT to SupCFRT and were collecting data for a larger ongoing study. This would suggest that while data collectors were not blinded to the results of each test, they had no inherent reason to bias their results, especially when they potentially used those results to alter their patients’ treatments.

Conflict of interest

The authors have no conflict of interest to report. No funding was obtained for this study.

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