A clinical study of patients with concurrent dizziness and neck pain

Dizziness is a relatively common complaint with a heterogeneous group of patients with several plausible causes. There has long been a controversy regarding the role of the cervical spine in dizziness and balance issues, even though there are well-established physiological connections between the vestibular, visual and cervical proprioceptive systems In addition, previous studies have shown that concurrent dizziness and neck pain exist in both patients with primary dizziness and patients with primary neck pain, resulting in a common clinical issue. However, there is little knowledge about the prevalence of patients with concurrent dizziness and neck pain and how neck pain influences patients with dizziness and balance. This project was a cross-sectional study of patients referred for either dizziness or neck pain to one of two outpatient clinics − an ear, nose and throat clinic or a spine clinic − both at Haukeland University Hospital in Bergen. The overall object of this thesis was to examine to what extent and how neck pain influences dizziness in terms of physical and dizziness characteristics, dizziness severity, postural control and quality of life. Our findings are presented in four papers. Paper I was a systematic review of the clinical characteristics of patients with cervicogenic dizziness. Only eight out of 2161 articles met our inclusion criteria. We found that reduced postural control measured with posturography was the most common clinical finding in patients with cervicogenic dizziness compared with other populations. Paper II examined differences in dizziness disability and quality of life in patients with and without neck pain, referred for dizziness to the ear, nose and throat clinic. Additionally, we examined whether neck pain was associated with a nonvestibular or vestibular diagnosis. We found that patients with additional neck pain reported higher dizziness disability and lower quality of life. In addition, there was no association between neck pain and the presence or absence of a vestibular disorder. Paper III explored the relationship between the pressure pain threshold in the neck and postural control in patients referred to both clinics. The patients were divided according 9 to their referred clinic and thus their primary complaint. In the patients referred for dizziness as the main complaint, we found a small, inverse relationship between pressure pain thresholds and sway area with eyes closed, after adjusting for age, sex and generalized pain. The same inverse relationship was found between pressure pain thresholds in the neck and the Romberg ratio on a bare platform after adjusting for age, sex and generalized pain. Neither of these relationships were present in the neck pain group. In Paper IV, we explored clinical symptoms and physical findings in patients with concurrent neck pain and dizziness from both centers and examined whether they differed from patients with dizziness alone. Both neck pain groups were associated with certain dizziness characteristics and increased physical impairment. The neck pain group, having dizziness as their primary complaint, had the highest symptom severity score. The overall findings of this thesis indicate that neck pain may affect postural control, dizziness symptoms, physical impairments and quality of life. As the relationship between dizziness and neck pain is a controversial topic, these finding may be helpful and should be considered when examining patients with concurrent complaints, regardless of diagnosis

The association between cognitive impairment, gait speed, and Walk ratio

Background: Gait speed has been found to be associated with cognitive function. However, gait speed is an unspecific measure that may not be informative about gait patterns. The Walk ratio (step length divided by step frequency) can be measured without specialized equipment, and has been suggested as an indicator of central gait control. However, the association with cognitive function is unknown. Research question: Is there a relationship between Walk ratio and cognitive function, and gait speed and cognitive function? Methods: This was a systematic literature review of studies where spatiotemporal gait parameters was reported in populations with cognitive impairment. The search was performed through PubMed, PEDro, AMED, Cochrane, Embase, MEDLINE, and PsycINFO. The studies had to contain either the Walk ratio, or report average step length and average step frequency. In the latter case, the average step length was divided by the average step frequency. The studies also had to report gait speed and the minimal mental state examination (MMSE). Studies testing patients on treadmills or that did not state the exclusion of patients with neurologic or orthopedic diseases, possible affecting gait ability, were excluded. Results: A total of 24 studies were included, consisting of 909 patients with cognitive impairment and 4,108 healthy controls. The patient group had a lower Walk ratio (mean difference 0.07, p ≤ 0.001) and gait speed (mean difference 0.26, p ≤ 0.001) than the healthy controls. Using linear regression models, we found an association between the MMSE and the Walk ratio (R2 = 0.29, p < 0.001) and gait speed (R2 = 0.41, p < 0.001) in separate, unadjusted models. In a final model with Walk ratio, gait speed and age, Walk ratio was not significantly associated with MMSE, while gait speed was. Significance: Our results suggest that preferred gait speed may be preferable to the Walk ratio when assessing older adults with cognitive impairment.publishedVersio

Measuring pressure pain threshold in the cervical region of dizzy patients-The reliability of a pressure algometer

Objectives: A tool for measuring neck pain in patients with dizziness is needed to further investigate the relationship between the two symptoms. The objective of this study was to examine the reliability and validity of a hand‐held pressure algometer in measuring pressure pain threshold (PPT) in different cervical regions of dizzy patients. Methods: PPT was measured at two bilateral standardized sites of the neck by a trained physiotherapist in 50 patients with dizziness. Intraclass correlation coefficients (ICC) were calculated for intrarater and test–retest reliability. Concurrent validity was assessed by measuring the association between PPT and the American College of Rheumatology (ACR) tender points at each site and with the numeric pain rating scale (NPRS). Results: Almost perfect intrarater (ICC = 0.815–0.940) and within‐session test–retest (ICC = 0.854–0.906) reliability was found between the measures. On each site, a low PPT predicted a positive ACR tender point at each site (OR = 0.864–0.922). Last, we found a statistical inverse relationship between the PPT and the NPRS (R = −0.52 to −0.66). Conclusion: The study shows that a pressure algometer is a reliable tool for measuring PPT in the neck of dizzy patients. Further, the PPT correlates significantly with other subjective measures of pain indicating that it may be a useful tool for further research.publishedVersio

Prevalence and distribution of musculoskeletal pain in patients with dizziness—A systematic review

Background and purpose Musculoskeletal disorders are among the leading causes of disability globally, but their role in patients with dizziness and imbalance is not well understood or explored. Such knowledge may be important as musculoskeletal pain and dizziness can mutually influence each other, leading to a complex condition requiring more comprehensive approaches to promote successful recovery. We conducted a systematic review to examine the extent and characteristic of reported musculoskeletal pain in patients with dizziness. Methods A comprehensive literature search in Medline, Embase, Cochrane, Scopus, Amed, Google Scholar, SveMed+, and Web of Science was conducted in March 2021. Inclusion criteria were studies examining patients with a vestibular diagnosis, patients with cervicogenic dizziness and patients included based on having dizziness as a symptom; and reported musculoskeletal pain. Data regarding age, sex, sample size, diagnosis and musculoskeletal pain was extracted. The Crowe Critical Appraisal Tool was used for assessing methodical quality of the included studies. Results Out of 1507 screened studies, 16 studies met the inclusion criteria. The total sample consisted of 1144 individuals with dizziness. The frequency of patients reporting pain ranged between 43% and 100% in the included studies. Pain intensity were scored between 5 and 7 on a 0–10 scale. Pain in the neck and shoulder girdle was most often reported, but musculoskeletal pain in other parts of the body was also evident. Discussion In the included studies, musculoskeletal pain was highly prevalent in patients with dizziness, with pain intensity that may have a moderate to severe interference with daily functioning. Pain in the neck and shoulder is well documented, but there are few studies addressing musculoskeletal pain in additional parts of the body. More research is needed to understand the relations between dizziness and musculoskeletal pain.publishedVersio

Musculoskeletal pain patterns and association between dizziness symptoms and pain in patients with long term dizziness – a cross-sectional study

Background The impact of long-term dizziness is considerable both on the personal level and in society and may lead to self-imposed restrictions in daily activities and social relations due to fear of triggering the symptoms. Musculoskeletal complaints seem to be common in persons with dizziness, but studies addressing these complaints as a widespread occurrence, are scarce. This study aimed to examine the occurrence of widespread pain in patients with long-term dizziness and investigate the associations between pain and dizziness symptoms. Further, to explore whether diagnostic belonging is related to the occurrence of pain. Methods This cross-sectional study was conducted in an otorhinolaryngology clinic and included 150 patients with persistent dizziness. The patients were categorized into three groups: episodic vestibular syndromes, chronic vestibular syndromes, and non-vestibular group. The patients completed questionnaires on dizziness symptoms, catastrophic thinking, and musculoskeletal pain when entering the study. Descriptive statistics were used to describe the population, and associations between pain and dizziness were investigated by linear regression. Results Pain was reported by 94.5% of the patients. A significantly higher prevalence of pain was reported in all the ten pain sites examined compared to the general population. Number of pain sites and pain intensity were associated with the dizziness severity. Number of pain sites was also associated with dizziness-related handicap, but not with catastrophic thinking. There was no association between pain intensity and dizziness-related handicap or catastrophic thinking. Pain was equally distributed in the diagnostic groups. Conclusion Patients with long-term dizziness have a considerably higher prevalence of pain and number of pain sites than the general population. Pain co-exists with dizziness and is associated with dizziness severity. These findings may indicate that pain should be systematically assessed and treated in patients with persisting dizziness.publishedVersio

Gait characteristics in people with cognitive impairment - the relationship between step length and cadence

Background: Approximately 70 000 people in Norway are suffering from some form of dementia. Gait and balance impairment in patients with Alzheimer's disease has been recognized for years. Reduced walking speed has been observed not only in patients with Alzheimer's disease, but also patients with mild cognitive impairment. However, the step length cadence relationship (walk ratio) is yet to be studied in individuals with cognitive impairment. Walk ratio has been suggested as a more specific variable than gait speed, as it says something about the quality of how we walk. Aim: The first aim of the thesis was to explore the association between the minimal mental state examination (MMSE)-score and walk ratio by reviewing relevant literature. The second aim was to see if walk ratio can predict group membership between participants with subjective cognitive impairment, mild cognitive impairment and healthy controls. Methods: A literature review of studies where either walk ratio or spatiotemporal gait parameters was reported in populations of cognitive impaired old persons was conducted. In addition, a cross-sectional trial with a 10- meter gait assessment for participants with subjective cognitive impairment, mild cognitive impairment and healthy controls was conducted. Results: The literature review yielded a strong correlation between walk ratio and MMSE - score (r = 0.69). Linear regression showed that age did not contribute significant to the model. The cross-sectional trial showed that walk ratio could not predict group membership to either mild cognitive impairment or subjective cognitive impairment. However, a decrease in velocity was predictive of both subjective cognitive impairment (OR = 0.967 95% CI 0.938 to 0.997, P = 0.03) and mild cognitive impairment (OR = 0.963, 95% CI 0.930 to 0.996, P = 0.03). Conclusion: There was a strong association between the MMSE - score and walk ratio. In addition, a decrease in velocity seems to be predictive of both mild cognitive impairment and subjective cognitive impairment. These findings support the fact that there is an association between degree of cognitive impairment and gait function and that gait impairment can be found in early stages of dementia

A clinical study of patients with concurrent dizziness and neck pain

Dizziness is a relatively common complaint with a heterogeneous group of patients with several plausible causes. There has long been a controversy regarding the role of the cervical spine in dizziness and balance issues, even though there are well-established physiological connections between the vestibular, visual and cervical proprioceptive systems In addition, previous studies have shown that concurrent dizziness and neck pain exist in both patients with primary dizziness and patients with primary neck pain, resulting in a common clinical issue. However, there is little knowledge about the prevalence of patients with concurrent dizziness and neck pain and how neck pain influences patients with dizziness and balance. This project was a cross-sectional study of patients referred for either dizziness or neck pain to one of two outpatient clinics − an ear, nose and throat clinic or a spine clinic − both at Haukeland University Hospital in Bergen. The overall object of this thesis was to examine to what extent and how neck pain influences dizziness in terms of physical and dizziness characteristics, dizziness severity, postural control and quality of life. Our findings are presented in four papers. Paper I was a systematic review of the clinical characteristics of patients with cervicogenic dizziness. Only eight out of 2161 articles met our inclusion criteria. We found that reduced postural control measured with posturography was the most common clinical finding in patients with cervicogenic dizziness compared with other populations. Paper II examined differences in dizziness disability and quality of life in patients with and without neck pain, referred for dizziness to the ear, nose and throat clinic. Additionally, we examined whether neck pain was associated with a nonvestibular or vestibular diagnosis. We found that patients with additional neck pain reported higher dizziness disability and lower quality of life. In addition, there was no association between neck pain and the presence or absence of a vestibular disorder. Paper III explored the relationship between the pressure pain threshold in the neck and postural control in patients referred to both clinics. The patients were divided according 9 to their referred clinic and thus their primary complaint. In the patients referred for dizziness as the main complaint, we found a small, inverse relationship between pressure pain thresholds and sway area with eyes closed, after adjusting for age, sex and generalized pain. The same inverse relationship was found between pressure pain thresholds in the neck and the Romberg ratio on a bare platform after adjusting for age, sex and generalized pain. Neither of these relationships were present in the neck pain group. In Paper IV, we explored clinical symptoms and physical findings in patients with concurrent neck pain and dizziness from both centers and examined whether they differed from patients with dizziness alone. Both neck pain groups were associated with certain dizziness characteristics and increased physical impairment. The neck pain group, having dizziness as their primary complaint, had the highest symptom severity score. The overall findings of this thesis indicate that neck pain may affect postural control, dizziness symptoms, physical impairments and quality of life. As the relationship between dizziness and neck pain is a controversial topic, these finding may be helpful and should be considered when examining patients with concurrent complaints, regardless of diagnosis

The association between cognitive impairment, gait speed, and Walk ratio

BackgroundGait speed has been found to be associated with cognitive function. However, gait speed is an unspecific measure that may not be informative about gait patterns. The Walk ratio (step length divided by step frequency) can be measured without specialized equipment, and has been suggested as an indicator of central gait control. However, the association with cognitive function is unknown.Research questionIs there a relationship between Walk ratio and cognitive function, and gait speed and cognitive function?MethodsThis was a systematic literature review of studies where spatiotemporal gait parameters was reported in populations with cognitive impairment. The search was performed through PubMed, PEDro, AMED, Cochrane, Embase, MEDLINE, and PsycINFO. The studies had to contain either the Walk ratio, or report average step length and average step frequency. In the latter case, the average step length was divided by the average step frequency. The studies also had to report gait speed and the minimal mental state examination (MMSE). Studies testing patients on treadmills or that did not state the exclusion of patients with neurologic or orthopedic diseases, possible affecting gait ability, were excluded.ResultsA total of 24 studies were included, consisting of 909 patients with cognitive impairment and 4,108 healthy controls. The patient group had a lower Walk ratio (mean difference 0.07, p ≤ 0.001) and gait speed (mean difference 0.26, p ≤ 0.001) than the healthy controls. Using linear regression models, we found an association between the MMSE and the Walk ratio (R2 = 0.29, p &lt; 0.001) and gait speed (R2 = 0.41, p &lt; 0.001) in separate, unadjusted models. In a final model with Walk ratio, gait speed and age, Walk ratio was not significantly associated with MMSE, while gait speed was.SignificanceOur results suggest that preferred gait speed may be preferable to the Walk ratio when assessing older adults with cognitive impairment

Association between musculoskeletal function and postural balance in patients with long-lasting dizziness. A cross-sectional study

Background and purpose Reduced balance and musculoskeletal pain are frequently reported among patients with long-lasting dizziness. However, the association between musculoskeletal function and postural sway among these patients has not been examined. The objective of this study was to examine if there is an association between aspects of musculoskeletal function and postural balance in patients with long-lasting dizziness. Methods This was a cross-sectional study, using data of 105 outpatients with long-lasting dizziness. Aspects of musculoskeletal function was assessed by examining body flexibility, grip strength, preferred and fast walking speed, in addition to musculoskeletal pain. Musculoskeletal pain was evaluated using the Subjective Health Complaints questionnaire. Postural balance was assessed by path length of postural sway by using a balance platform on both firm and soft surfaces, with eyes open and closed. The association between musculoskeletal function and postural sway was assessed using linear regression analyses. Results When adjusting for age and gender we found that on a firm surface, there was an association between increased musculoskeletal pain and increased postural sway measured with eyes open (p = 0.038). In addition, there was an association between decreased body flexibility and decreased postural sway with eyes open (p = 0.025). On a soft surface, decreased fast walking speed was associated with increased postural sway with eyes open (p = 0.027). In addition, decreased grip strength was associated with increased postural sway on a soft surface with eyes closed (p = 0.015). Discussion The findings from this study imply that musculoskeletal function may associate with postural sway in patients with long-lasting dizziness, although the associations were weak

Clinical characteristics in patients with cervicogenic dizziness: A systematic review

Background and aims: Cervicogenic dizziness (CD) is a clinical syndrome of dizziness associated with neck dysfunction. CD represents a considerable diagnostic challenge since dizziness and neck pain are common symptoms with complex and multifactorial etiologies. Both research and clinical work on CD is limited by the lack of accepted diagnostic criteria. The aim of this study was to review clinical studies on CD and to assess current evidence regarding the clinical characteristics of this syndrome. Methods: A comprehensive PubMed and MEDLINE search was conducted from the date of inception of the database, with the last search conducted in September 2018. Included studies had to contain operable diagnostic criteria as well as a comparison between patients considered to have CD and a clinical comparison group. Data extracted were clinical outcomes, diagnostic criteria, age, sex, and sample size. Studies were assessed for methodological quality using the Crowe Critical Appraisal Tool. Results: Out of 2161 screened studies, eight studies comprising 225 patients met the inclusion criteria. Studies were of low to acceptable methodological quality. The most frequent and consistent clinical characteristic in patients classified as having CD, compared with other populations, was reduced posturographic stability. The most consistent diagnostic criteria were based on the concurrence of neck pain with dizziness after exclusion of other possible reasons for dizziness. Conclusion: There are few studies examining clinical characteristics in patients with cervicogenic dizziness. Altered posturography appeared to be the only consistent characteristic used when distinguishing CD from other populations. Diagnostic criteria currently used in research are likely to have low specificity, since they rest on the exclusion of other causes rather than on positive distinctive features. More studies are needed to better understand the clinical interrelations between dizziness and neck pain