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Somatic referred pain and
movement pattern, cervical spine pain and cervical vertigo
Somatic movement restrictions can have an 'opening'
or 'closing' pattern. Generally these conditions respond extremely
well to joint mobilisations, Mulligans techniques, Occulomotor reflex
patterning exercises, soft tissue massage, dry needling, and exercises
for scapula and pelvic symmetry. Additionally, thoracic joint and
rib movements usually require assessment for inferior lateral respiratory
excursion as well as scapulothoracic mobility. The serratus anterior
and trapezius muscles generally require specific attention regarding
scapula stability. It should be remembered that somatic movement
disturbances will create spasms in some muscles whilst weakness
in others. In turn these altered muscle patterns place dysfunctional
and asymmetrical loading on the joints.
Cervical Kinesthesia and Occular Reflexes
Basic somatic referral patterns
somatic referral due to neurogenic inflammation
Headache - cervicogenic
Cervical Proprioception
-
Clinical aspects of proprioceptive dysfunction
have not been researched extensively (Kristjansson 2005)
-
Proprioception is a complex neurophysiological
pathway which plays a small but important role in motor control
(Gandevia & Burke 1992)
-
The cervical spine has great mobility at the
expense of mechanical stability and a close neurophysiological
connection to the vestibular and occular systems (Gimse et al
1996)
-
Perception drives the motor responses. Motor
strategies and 'feed forward' preparatory responses are instigated
by the CNS to drive the PNS. The CNS stores sensory perceptions
in memory. However, sensory conflict may arise when incoming
disturbed proprioceptive information is unexpected leading to
altered 'efference-afference copy'
-
This hierarchical model has been criticised
as it does not explain reactions to novel tasks, nor can the
memory bank store all the information needed for complex co-ordinated
motor tasks required to solve for the control of multiple 'degrees
of freedom' problem proposed by Bernstein (1967)
-
Treatments built into hierarchical ways of
thinking (Knott & Voss 1968) have been criticised for being
too passive because therapeutic interventions were modelled
on facilitation and inhibition rather than function training
(Shumway-Cook & Woollacott 2001)
-
Systems theories
examine the functioning of the whole, where self organisation
occurs based on principles of physics whereby constraints within
an organism, a task and the environment determine which movement
strategies are best for each individual as a whole (Shumway-Cook
& Woollacott 2001) - integration of neuro-musculo-skeletal
with vestibular, occular and immune.
-
Clinically, treatment needs to be functionally
meaningful and task dependent to appeal to the clients perceptions
and cognitions.
Phylogenetics
- When the vertebrates evolved in the ocean, the whole body,
including the head, formed a spindle-like unity to enable fast
swimming. Spatial orientation was served by peripheral vestibular
and visual systems
- About 350million years ago when vertebrates climbed onto
the land, to be able to survive, their head had to be able to
move freely on the rest of their body
- The first rudimentary head on neck motion was a nodding action
occurring at 0/C1
- However, this wasn't enough and development of the dens axis
enveloped by the ring of the atlas followed (Wolff 1998)
- Last major development took place at C2/3 which facilitated
coupling of movements
- These bony developments were accompanied by distinct development
of the musculature of the upper cervical spine to orient the
head sensors in space
- A network of mechanoreceptors were developed to provide information
of the head in regard to the rest of the body
The Cervical Spine and the Postural Control System
- the vestibular, visual and somatosensory systems
- The semicircular canals used to determine changes in the
rate of motion, angular velocity
- The otoliths containing the utricular and saccular maculae
provide information on linear velocity and gravity (head tilt)
- Convergence occurs in the vestibular nuclear complex (VNC)
via the vestibular nerve and cerebellum
- The vestibulo- and reticular-spinal tracts provide impulse
propagation to the trunk & limbs
- The upper cervical mechanoreceptors have indirect inputs
into these descending tracts
Visual System & Audition
- Over 1/3 of the brain in primates is devoted to vision (Stein
& Glickstein 1992)
- The visual postural system consists of 2 movement - smooth
pursuit, saccade, opticokinetic
- The vestibular-ocular reflex (VOR) stabilizes images on the
retina
- The position and movement of the head in relation to the
rest of the body and eye movements is regulated by the VOR and
the much weaker cervico-ocular reflex (COR) where the latter
acts on the extra-ocular muscles.
- However, in dysfunctional conditions the COR becomes more
active and can be used for differential diagnosis of upper cervical
spine proprioception (Neuhuber 1998, Tjell 1998)
The somatosensory subsystem
- Upper cervical spine has an abundance of mechanoreceptors,
esp. from the gamma muscle spindles (nuclear bag and nuclear
chain fibres) of the deep segmental muscles (Richmond &
Bakker 1982), these impulses converge in the central cervical
nucleus (CNN)
- The cervical mechanoreceptors have direct inputs to the VNC
via the DRG at the C2 and C3 levels which contrasts to inputs
from lower spine segments which tapper off to indirect inputs.
- Inputs from lower spinal segments converge onto the cuneatus
nuclei and travel from there to the cerebelllum (Neuhuber 1998)
- The CNN has important connections to the VNC. The lateral
VNC is the origin of the powerful lateral vestibulospinal tracts
which controls muscle tone in the trunk and extremeties (Tjell
1998)
- The cervico-collic reflex (CCR) is mediated through these
pathways and probably the medial vestibolospinal tract via the
VNC (Peterson et al 1985). The CCR is stimulated by cervical
movements and dampens the activity of the VOR and VCR stimulated
by the semi-circular canals
The nociceptive system
- The nociceptive system in the upper cervical spine projects
onto many cranial afferents of which the trigeminal nucleus
and the tractus solitaritus nuclear complex (Vagal nerve) are
the most important ones.
- Neuroanatomical research indicates connections from the upper
cervical spine to the limbic system (Feil & Herbert 1995;
Neuhuber 1998)
- Coordination of movement is mainly the function of the cerebellum,
where all spinal and brain stem reflexes directly or indirectly
converge (Stein & Glickstein 1992)
- Linear Vestibulocollic Reflex (VCR)
- Little is known about the otoliths
- The otoliths are stimulated by linear accelerations of the
head and their inputs have been found to modify both eye and
head stabilizing responses (Schor et al 1985)
- Otolith contributions to compensatory eye and neck responses
increased with stimulus frequency, but the otolith system alone
is unable to produce perfect compensation (Boral & Lacour
1982)
- ? Convergence of canal and otolith input on vestibulospinal
neurons combine to provide reflexes to linear and angular acceleration
? (Uchino et al 2000)
- ? Otoliths may have a distinct functional affect during locomotion
providing compensatory head pitch movements by the angular VCR
during walking and the linear VCR during running ? (Hirasaki
et al 1999)
Multimodal Control
- The reflexes appear to be predominant in the frequency of
natural locomotion (1.5-2Hz) (Hirasaki et al 1999) and their
function is to damp oscillations of the head at higher frequencies
(Keshner et al 1999)
- Voluntary responses are observed as anticipatory torques
in the neck muscles or responses controlled by the occulomotor
reflex
- Above 1Hz mechanical factors (inertial, stiffness and viscoelasticity)
become important
- The relative importance of the VCR and CCR for head-neck
stabilization is probably dependent upon the degrees of freedom
and the postural requirements of the task (Keshner 2005)
Motor Control
- Complex biomechanical linkage with 20 pairs of muscles capable
of performing similar actions -> therefore suggesting some
redundancy in the system
- Overall the number of independently controlled muscle elements
exceeds the number of degrees of freedom of neck motion ->
the extent of functional variability depends upon the task being
studied
- Head represents 7% body weight, yet has 20 different muscles
directly linking the skull in either side of midline to the
vertebral column
- Motions of the head are primarily directed towards orienting
and stabilizing the position of the eyes and head in space
- CNS programmes neck muscles in specific directions rather
than an infinite variety of muscle patterns
- Muscles organised in layers - outer layer connects skull
with the shoulder girdle - deeper layer links the skull with
the vertebra
- deepest layer consists of muscles that link the cervical and
thoracic vertebrae
- The layer of muscles linking the skull to the vertebrae form
the long dorsal (splenius capitis, semispinalis capitus and
longissimus capitis) and a long ventral (longus capitus) muscle.
- > act as a sleeve for the cervical vertebrae eg rotation
- Splenius cervicis, Semispinalis cervicis, longissimus cervicis
& longus colli lie deeper, have a small moment arm - >
proprioceptive function
- Suboccipital muscles produce extension at the atlanto-occipital
joint.
Neck muscle morphometry
- Each muscle differs in it's relative content of fast and
slow twitch fibres, angles of pennation, sarcomere length, sites
of origin and insertion and the mechanics of action across the
individual joints
- Unlike limb muscles where there is a distinct tendonous attachment
to bones, many neck muscles had very little tendons at their
ends.
- Instead of distinct tendons, many neck muscles have a complex
architecture of internal tendons and aponeuroses. (Kamibayashi
& Richmond 1998)
Functional Synergies
- One solution to controlling the degrees of freedom (Bernstein
1967) is to organise movement around synergistic muscle torques
(Buchanan et al 1989)
- In cats, dissociation between deep and superficial neck muscle
activation suggests different neural controllers (Richmond et
al 1992)
- Separation of two groups of muscles, one producing the forces
necessary to move the head and another to align the head with
the terminal target would assist the head-neck controller in
meeting multiple criteria or goals (Thomson et al 1994)
- A single action can be accomplished through the activation
of agonists and antagonists where the control parameter appears
to be the required force vector rather than the specific force
lever arm of any particular muscle (Macpherson 1988, 1991) -
therefore the specific direction of motion is important
Directional tuning of muscles
- Each muscles preferred direction is unique and consistent
amongst subjects (flexion for sternocleidomastoid, ipsilateral
flexion for splenius capitis and extension for semispinalis
capitis. Trapezius was tuned toward lateral flexion but had
the lowest activation and the greatest variability)
- Rotation shifted the maximal activation vectors away from
the moment arm direction due to the observation that none of
these muscles produce a unique axial rotation torque (Keshner
2005)
- A likely control parameter for the CNS to employ in the selection
of which muscle to employ may be contingent upon it's ability
to generate a maximal mechanical advantage (Keshner et al 1997)
- Posture affecting the plane of motion of the muscles length
and pulling direction may have a greater influence on its contribution
than mechanical efficiency (Runciman & Richmond 1997)
- Orientation of the C/S (ie perpendicular or horizontal to
earth) was a significant variable in determining the ROM, amplitude
and timing of the neck muscles (Statler & Keshner 2003)
Neural Control of the Cervical Spine
- Vestibulocollic (VCR) and cervicocollic (CCR) reflexes, respond
reactively to accelerotory and proprioceptive stimuli to maintain
the orientation of the head in space (VCR) and the head on trunk
(CCR).
- Voluntary responses are those for tracking and acquiring
exteroceptive (visual, auditory and olfactory) information and
can be used either anticipatorily or pursuit actions
- The normal repertoire of movement responses emerges from
combinations of input and output signals (Keshner 2005)
- Vestibulospinal pathways have monosynaptic and disynaptic
connections with cervical motor neurons
- Cervical proprioceptive inputs have significant influence
on the vestibulospinal signals (Gdowski & McCrea 2000) and
together with the reticulospinal neurones have a major influence
on orientation and posture through convergence of afferent input
which initiates a series of interspinal reflexes
- The VCR alone is not sufficient for purposeful head stabilization
in a dynamic environment (Keshner 2005) suggesting that other
inputs such as the reticulospinal are also involved.
- Gdwoski & McCrea suggest correct alignment of the head
and trunk requires ascending somatosensory inputs. The CCR arises
from a stretch of the neck musculature as would occur when turning
the body with a fixed head position. This reflex is more complex
than a monosynaptic reflex, with evidence of presynaptic inhibition
in the CCR response (Banovetz et al 1995)
Neck muscle activation patterns
- Each head motion is executed by a specific muscular pattern
that is not repeated in any other direction
- Motor solutions to voluntary head tracking need constant adjustment
whereas the VCR and CCR probably only need to stabilize specific
cervical joints.
Cervical Vertigo
- Dizziness is the third most common reason to seek medical
advice in the USA (Kroenke & Mangelsdorff 1989)
1.8% in young adults to 30% in elderly (Sloane et al 2001)
- Up to 80-90% of patients suffering chronic whiplash report
vertigo & dizziness (Oosterveld et al 1991)
4 categories of cervical vertigo
- Vertigo : “sensation of irregular or whirling motions,
either of oneself or of external objects”
- Near-syncope
- Disequilibrium
-Light headedness (40-50% of attacks are vertigo)
Differential Diagnosis with
- Vertigo (canalolithiasis and cupulolithiasis)
-Prolonged spontaneous - positional vertigo (BBPV) -recurrent
attacks
- Meniere’s Disease
- Vestibular Neuritis
- Labyrinthitis
- Periplymphatic Fistula
- Bilateral Vestibular Dysfunction
- Central causes
- Vestibular Schwannoma
- Arnold-Chiari Malformation
- Vertiginous Migraine
- Psychogenic Dizziness
- Mal de debarquement syndrome
- Pharmacological
Cervical Vertigo
-
‘spinning of the head’ rather than
spinning of the patient, light headedness, tipsy feeling, as
a consequence of ‘noise ‘ in the PNS
-
Usually worse in the morning and tappers during
the day
-
Associated with neck movements but also with
tracking an object or driving a car (Hulse & Holzl 2000)
-
Tend to increase in intensity over time as mechanoreceptors
are non-adaptive and their threshold decreases over time if
left untreated (Neuhuber 1998)
-
Some people don’t perceive dizziness however
they have overall increased muscle tone which may explain why
some people go on to develop fibromyalgia
-
In long-standing cases the plasticity of the
CNS (Sessle 2000) may make them treatment resistant to traditional
manual therapy and techniques employing virtual reality training
become important (WiiFit balance exercises), yoga, Tai Chi,
etc
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Visual disturbances although common are not
widely accepted due to the lack of verification using conventional
opthalmologic instruments (Hulse 1998) – these people complain
of blurred vision, reduced visual field, grey spots appearing
in the visual fields, temporary blindness, disordered fusion,
whole words or whole sentences ‘jump’, double vision
but not true diplopia (as with VBI), and reading problems (Hulse
1998)
-
Existence of cervical vertigo is controversial
as otoneurological examination are frequently normal
-
Incidence appears to be highest in the 30-50
year old and more common in females
-
The diagnosis of cervicogenic dizziness is based
on history, examination, and vestibular function tests
-
Vascular hypothesis - Vertebral artery
vasospasms due to close relationship with the sympathetic nerve
trunk
However this would be accompanied by serious neurological symptoms
such as diplopia, dysarthria, ataxia & motor symptoms
The vertebral artery is at risk in artherosclerosis.
-
Degenerative changes in the uncinate processes
of the low C/S projecting osteophytes laterally, and/or
subluxating superior articular processes (Bogduk 1986)
-
Full rotation of the C1/2
-
Deep fascial bands of cervical muscles crossing
the artery, anomalous course of the artery between fascicles
of either longus colli or scalenus anterior (Bogduk 1986)
-
Neurovascular hypothesis
-
Sympathetic Nervous System
-
C3/4 osteophytes and irritation of superior
cervical ganglion ((Tamura 1989)
-
Direct irritation of sympathetic ganglia
within fascia of anterior cervical muscles after whiplash
-
Erroneous proprioceptive signalling due
to gamma reflexogenic activation of muscle spindles (Johansson
& Sojka 1991)
-
However SNS blocks induces vertigo, tendency
to fall, horizontal nystagmus & tinnitus, instead of
diminishing the symptoms (Barre 1926, Lieou 1928 in Heikkila
2005)
-
Somatosensory hypothesis :
-
Disturbed afference – efference copy
due to
-
Abnormal sensory input from neck proprioceptors
-
Vestibulo-occular reflex (VOR) stabilizing
the visual field
-
Vestibulocollic reflex (VCR) stabilizing
the head position
-
Cervicooccular (COR) proprioceptive
reflex - helper reflex if the labyrinths have been damaged
(Botros 1979), co-operates with the VOR for clear vision
– originates in neck and joint proprioceptors
-
Cervicocollic (CCR) proprioceptive reflex
– stabilizes the neck and protects from over-rotation
and coutneracts the COR, probably generated by the gamma
muscle spindles of the deep neck muscles (Hirai et al
1984)
-
Vestibulospinal reflexes – appropriate
tone for the neck and body muscles for the purpose of
balance
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Impaired kinaesthetic performance was found
in people with dizziness/vertigo of cervical origin which
may be as a result of lesioning or functional impairment
of muscular and articular receptors, or by alteration in
afferent integration and tuning (Heikkila et al 2000; Wyke
1979, Taylor & McCloskey 1988)
-
Altered kinaesthetic sensitivity has been
implicated in functional instability of joints and their
predisposition to re-injury, chronic pain and degenerative
joint disease (Revel et al 1991, Hall et al 1995)
-
Postural control and voluntary eye movements
were impaired during cervical restriction with a collar
(Karlberg et al 1991)
-
Smooth pursuit and saccade abnormalities
have been reported in people whiplash (mild – due to
altered C/S proprioception {Oosterveld et al 1991}, severe
– due to medullary lesions {Hildings et al 1989}),
and in people suffering from fibromyalgesia with dysaesthesia
(Rosenhall et al 1987)
-
62% of whiplash patients had at least 1
smooth pursuit abnormality at 2 years follow-up (Heikkila
& Wenngren 1998)
-
Smooth pursuit was correlated with active
ROM function of the C/S (Heikkila & Wenngren 1998; Karlberg
et al 1991)
-
Vertigo was reported in 85% of whiplash
subjects (Oosterveld et al 1991)
-
Whiplash subjects had less accurate ability
to relocate their head in space after active displacement
that turned their head away from the reference position
(Heikkila & Astrom 1996) – esp. vertical mov’ts
-> correlates with hyperflexion/extension injury
Signs & Symptoms of Cervical Vertigo
-
Correlating symptoms of imbalance with neck
dysfunction
-
Cervical vertigo is characterised by a feeling
of unsteadiness when standing and walking rather than rotatory
vertigo (Brandt 1991)
-
Accompanied by pain – occipital, temporal,
temporomandibular to orbital or forehead region
-
Tenderness on cervical palpation
-
Dizziness and nausea may be provoked by palpation
of the lateral mass of the atlas (Scherer 1985)
-
Blurred vision, photophobia, direction-fixed,
directional changing positional nystagmus, tinnitus, low frequency
hearing loss
-
Imbalance may occur during the Unterberger stepping
test
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Correlating subjective findings (mechanism of
onset, history of duration, frequency, area, and intensity)
with physical and functional impairment is important in making
a diagnosis and monitoring progression
-
Questionnaires
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Activities Specific Balance Confidence Scale
(ASBCS) (Powell & Myers 1995) & Dizziness Handicap
Inventory (Tesio et al 1999)
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Dynamic Gait Index (Shumway-Cook & Woollacott
2001) & Berg Balance Test (Berg et al 1992)
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Cranial and carotid pulse and assessment for
varicose veins
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Complete neurological examination in all patients
presenting with undiagnosed disorder of equilibration
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Gait and balance and spontaneous nystagmus
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Clinical test for Sensory Interaction in Balance
(CTSIB) ‘foam & dome test’ - quiet standing eyes
open/eyes shut, and again on foam for 15-30secs each (Shumway-Cook
& Horak 1986) -
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Posturography + vibration to the cervical extensors
(illusion of lengthening) (Karlberg et al 1996) - measures the
force applied by the patients feet
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Assess dynamic visual activity – smooth
pursuit neck torsion (SPNT) test, saccade tests, relocation
error testing
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VBI testing – positive predictive validity
is zero, negative predictive value ranged from 63 – 97%
(Cote et al 1996)
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Unterberger stepping and Romberg quiet standing
tests
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Cervical Range of Motion testing ; extension
stimulates the utricles
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Adverse neural tension testing
-
Muscle and Joint Palpation – passive accessories,
passive physiological
-
Shoulder, Scapula and thoracic spine
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Head fixed body rotation manoeuvre - COR &
CCR is activated without activation of the semicircular canals
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Relocation testing using light on the head and
moving into flexion/extension, and rotation - see above
-
Visual Disturbances
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Smooth Pursuit Neck Torsion Test (SPNT)
(Rosenhall et al 1996)
-
Tests the reflex interaction between smooth
pursuit system and the proprioceptive system of the cervical
spine
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Velocity of eye movements relative to target
object – net gain is calculated; abnormal result is
reduced gain in the direction in which the head is rotated
-
When the body is rotated beneath a stationary
neck a nystagmus can be induced
e.g. when the trunk is rotated left, the head is in relative
right rotation, the COR helps the VOR to stimulate eye movements
to the left in this position, but for teleologic reasons,
in order to look forward, the saccadic system moves the
eyes to mid point. The VOR with the aid of an overactive
COR moves the eyes again to the left inducing a right-directional
nystagmus (Tjell 1998, Tjell & Rosenhall 1998)
-
Dix – Hallpike manoeuvre for BPPV
The patient is in long sitting with the head rotated 45degrees
to the side to be tested, then the patient is moved quickly
into supine with the head in 30degrees of extension over a pillow
under the rib cage, during which the eyes are observed for nystagmus
for the posterior semicircular canals
85% of BPPV are upward rotating due to the posterior semicircular
canals
-
Cervicocephalic kinaesthetic sensibility (position
sense + movement sense)
“kinaesthesia is a sensation which detects and discriminates
between the relative weight of body parts, joint positions,
and movements, including direction, speed and amplitude”
(Newton 1982) -> the qualities that are supposed to be the
result of proprioception
-
Target matching is used to relocate the
natural head posture (NHP) or to actively relocate a set
point in range (Kristjansson et al 2003) in the transverse
and saggital planes
-
Studies have demonstrated reduced relocation
accuracy in whiplash patients (Heikkila & Wenngren 1998)
but variable results in insidious neck pain (Kristjansson
et al 2003)
-
60% sensitivity and 80% specificity (Kristjansson
– unpublished work 2002)
-
Movements on the transverse plane stimulate
mainly the semicircular canals, those in other planes stimulate
the utricular otoliths which are sensitive to gravitational
changes (Taylor & McCloskey 1990)
-
Slow movements test cervical proprioception
due to the inertia of the cupula in the semicircular canals
-
An important aspect of proprioception is
moment-to-moment feedback from tracking fast and unpredictable
movements -> ‘the fly’ computer program with
a Fastrak device is used for such determination (Kristjansson
et al 2003, 2004)
Treatment
-
Positive affects have been reported for manipulative
treatments (Cronin 1997, Galm et al 1998; Hulse et al 2000)
-
Both acupuncture and manipulation reduced dizziness/vertigo,
neck pain and improved head repositioning error (Heikkila et
al 2000)
-
Postural training with a significant eye-neck
coordination component (Revel et al 1994) and vestibular component
(Yardley et al 1998) have been shown to improve posture and
dizziness
-
Multimodal approach advocated (Bracher et al
2000)
-
Recruitment of deep cervical flexors in neutral
head and shoulder position (Jull 2000)
-
Loss of cervical lordosis in chronic whiplash
patients (Kristjansson & Jonsson 2003) due to weak deep
cervical flexors of the upper cervical spine (Jull 2000) and
deep cervical extensors of the lower cervical spine (Kristjansson
2005)
-
Adequate movement control through range of motion
-
Determine whether global or segmental (upper,
mid, low) stability has been lost
-
If segmental then try to move areas below
and above the unstable segment keeping the latter stable –
cognitive control
-
Next step is to recruit global and local stabilizers
which most effectively move the dysfunctional segment under
active control in a specific direction – the patient
can be taught to only move the decontrolled segment through
controlled ROM or move the whole cervical spine
-
The patient is specifically taught to control
inner range and to move eccentrically from inner range to
mid range and in some cases outer range (depending upon functional
task which requires reinstating) (Kristjansson 2005)
-
There has been little research to the effectiveness
of treatment strategies aimed at improving neuromuscular control
and head carriage in the cervical spine
-
Revel et al (1994) conducted an 8 week eye-neck
co-ordination exercise and awareness of movement with significant
improvements in neck pain
Olafsdottir & Helgadottir (2001) conducted an ‘awareness
through movement’ Feldenkreis program. After 4weeks significant
improvements in NHP was detected (5.22deg + 1.79 vs 3.32 +
1.27 after treatment), additionally significant improvements
in the Northwick Park Disability Index occurred using a 100mm
VAS (Leak et al 1994)
-
Virtual reality systems to accommodate the need
for ‘systems’ treatment eg. WiiFit, etc
-
Shock absorbing through the use of a trampoline
-
Eye-head coordination
-
Moving the eye balls with eyes open and shut,
-
visual tracking tasks with the head still,
-
gaze stability exercises whilst moving the head
slowly and later progression to rapid movements,
-
keeping the gaze stability whilst moving in
phase with the patients head in sitting, standing and walking,
moving the trunk or varying the surface whilst maintaining the
gaze on a fixed target
-
Balance exercises
-
Tandem stance on varying surfaces with eyes
open/shut
-
Walking on the spot with eyes shut
-
Walking with saggital and transverse plane movements
of the head and neck,
-
walking a distance and turning rapidly and walking
back,
-
standing on a balance board making various head
movements progressing to tracking a moving object,
-
walking on a treadmill detecting movements in
the periphery without looking,
-
walking blindfolded
-
Task dependent exercises
-
Repeat the movement that makes one dizzy
-
General endurance exercise
go to: radicular referred
pain
Updated 17 November 2009
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