Cervicogenic PCS Patient Form

Cervicogenic PCS
Patient Name*

First NameLast Name
Date*

MonthDayYear
Date
Purpose: In the context of Post Concussive Symptoms, cervicogenic components need to be addressed in this case. The goal is to recreate headaches, dizziness, and/or dysfunctional patterns that may be causing symptoms. The key to differential diagnosis of cervicogenic concussion symptoms is testing if cervical afferents cause symptoms or disruptions in balance and oculomotor control. This is not a standard orthopedic examination of the cervical spine.
Sense of Unsteadiness*

YesNo
Sense of Dizziness*

YesNo
Sense of “Feeling Off”*

YesNo
Vision Related Symptoms
Visual Fatigue*

YesNo
Sensitivity to Light*

YesNo
Blurred Vision*

YesNo
Difficulty Reading*

YesNo
Words Move on Page*

YesNo
Clinical Examination
Trigger Points: Trigger points (TPs) are not simply indurations or muscle knots. When adequately stimulated, TPs exhibit referred pain phenomenon and often autonomic phenomena. TPs can be latent or active. Cervical Referral Patterns for Headaches were assessed via the following trigger point regions:
Splenius Capitis (refers to top of head)*

YesNo
Suboccipitals (refers to temporal region)*

YesNo
SCM (refers supraorbital, vertex, auricular)*

YesNo
Superior Trap (refers suboccipital and temporal)*

YesNo
Semispinalis Capitis (refers in hatband)*

YesNo
Occipitalis (refers posterior head / retro-orbital)*

YesNo
Longus Coli (refers occipital/auricular regions)*

YesNo
Cervical Facet Joints: Deep palpation of the cervical facet columns revealed:*

NegativePositiveRightLeft
Doctor's Notes*
Cervicogenic Dizziness
Notation: Cervicogenic dizziness is generally not true vertigo (the room does not spin and there is no nystagmus). These patient's generally "just feel off". They have greater difficulty with extension but generally don't have problems lying supine. Cervicogenic vertigo patients were more likely to report that their symptoms increased with looking up and reporting that quick movements of their head increased their symptoms vs. other forms of dizziness (Reid et al. 2017).
Cervical Extension: Elicit Dizziness?*

YesNo
Rotatory Chair Test*

NegativePositive
Cervical Flexion / Rotation*

NegativePositive
Sensorimotor Impairment
Notation: There are three pillars of Sensorimotor Impairment:
- Proprioception
- Oculomotor Control
- Postural Stability
There are tremendous neurological connections between cervical muscle spindles and eyes (Cervico-Ocular Reflex = COR) and vestibular apparatus and eyes (Vestibulo-Ocular Reflex = VOR). These are the fastest reflexes in the body telling the eyes to move at exactly the same rate as the neck when turning the head. If one of these mechanisms is off -- the patient will "feel off".
Proprioception:

Cervical Joint Position Error Test (JPET) *

	1st	2nd	3rd
Right Rotation
Left Rotation
Flexion
Extension

Oculomotor:
Smooth Pursuit Neck Torsion Test (SPNTT)Cervical Facet Joints: Deep palpation of the cervical facet columns revealed:*

Neutral NormalNeutral SaccadesRight Rotation NormalRight Rotation SaccadesLeft Rotation NormalLeft Rotation Saccades
Near Point Convergence Neck Torsion Test
Neutral:   Number*   cm
Right Rotation   Number*   cm
Left Rotation:   Number*   cm
Postural Stability:
Tandem Stand (eyes closed)*

NegativePositive
Head Turns (walking)*

Rt Rotation NegativeRt Rotation PositiveLt Rotation NegativeLt Rotation PositiveExtension NegativeExtension PositiveFlexion NegativeFlexion Positive
DIAGNOSES (ICD-10)
Concussion W/O LOC (Subsequent Visit)*

YesNo
Concussion W/ LOC < 30 Min (Subsequent Visit)*

YesNo
Concussion W/ LOC Unspecified Duration (Subsequent Visit)*

YesNo
Persistent Concussive Symptoms (PCS)AKA Post Concussion Syndrome*

YesNo
Convergence Insufficiency*

YesNo
Dizziness*

YesNo
BPPV*

YesNo
Any additional diagnoses?
PLAN / RECOMMENDATIONS
Cervicogenic PCS Testing*

PassedFailed
Cervicogenic Rehab Prescribed: When prescribed, each exercise is reviewed with the patient in detail. The patient is also given a detailed instruction handout. It is important the patient performs the exercises 3-4x/day. The patient indicated any understanding.*

Cervical Proprioception RehabVestibulo-Ocular Rehab Level 2 with Cervical ProprioceptionVestibulo-Ocular Rehab Level 3Convergence Insufficiency w/ Neck TorsionBrock String Rehab w/ Neck Torsion
Schedule:*

Physiologic Testing (BCTT / BCBT)Vestibulo-Ocular EvalCervicogenic EvalBESS Testing
Neurocognitive Testing Reviewed*

YesNo
Neurologic Co-Management Reviewed*

YesNo
Psychological Complicating Factors Present*

YesNo
Time: Today, I spent * minutes reviewing the patient’s current status, outcome measures, performing a Cervicogenic PCS evaluation, discussing my recommendations, documenting my findings and completing the chart note. The patient indicated an understanding of our discussion and we will implement the above treatment plan.
Tests Reviewed*

99203 (New Patient; 30-44 Min)99211 (Est Patient; Brief OV)99212 (Est Patient; 10-19 Min)99213 (Est Patient; 20-29 Min)99214 (Est Patient; 30-39 Min)99215 (Est Patient; 40-54 Min)97112 (Neuromuscular Re-education)
Doctors Notes:*
Provider Signature*

Clear
Date*

MonthDayYear
Date
C 2022 First Care Concussion Clinic, LLC
Should be Empty:

Cervicogenic PCS

Clinical Examination

Cervicogenic Dizziness

Sensorimotor Impairment

DIAGNOSES (ICD-10)

PLAN / RECOMMENDATIONS