Fellowship Reflections: C2/3 Dysfunction

A patient came in with complaints of dizziness, facial tingling, disturbed vision/hearing and pain in her neck.  She had history of a bad MVA approximately 25 years ago and her symptoms had persisted since the accident. During subjective history she mentioned that all of her previous physicians thought she was crazy. As I was performing the subjective examination, I thought her symptoms sounded like what Erl Pettman has described as “trigeminal symptoms.” It occurred to me she might have a C2/3 dysfunction that was contributing to trigeminal convergence creating these symptoms.

I asked her whether her vision seemed murky or like looking through a dirty window and she immediately started crying. She confirmed that was exactly how it felt and she has never been able to describe it to her doctors sufficiently.

Long story short, after a careful screening, I utilized a focused cranial-directed (thrust) manipulation on C3 and her murky vision was completely abolished. She cried multiple times during the initial evaluation and she said she finally found someone who understands what she has. I treated her four times, and she has not complained of any dizziness, facial tingling, pain or disturbed vision/hearing!

I was never skeptical about the trigeminal symptoms diagnosis/treatment, but I wanted to take the time and share that the NAIOMT system works—my fellowship training has elevated my practice to levels I could have never imagined. I’m not the world’s greatest PT, greatest manipulator, or greatest diagnostician, but I am learning and getting better.



Summit Peak Physical Therapy, Arlington, Texas

5 thoughts on “Fellowship Reflections: C2/3 Dysfunction

  1. Thanks for sharing. I would have probably refered the pt to physician with those s/s. What helped you decide she was appropriate for tx and ok for manip? Thx


    1. Thank you both for your kind words! The topic of Trigeminal Symptoms of Cervical Origin (TSCO) is complex and exciting. While I am a graduate of the NAIOMT Fellowship Program, I am not a faculty member of the Institute. Thus, if you haven’t already taken NAIOMT courses, I urge you to consider them as our Faculty will provide a much more thorough perspective into TSCO. I will give you a very short synopsis and strongly suggest reading the referenced articles to gain further perspective.

      Following the subjective examination, TSCO was my primary working hypothesis. Following a lengthy screening process to determine the presence of any adverse dysfunction and safety concerns,I performed a bio-mechanical examination of the cervical spine and determined there was a hypo- mobility at C23 zygapophyseal joint (ZJ). One of NAIOMT’s chief educational principles is to know who NOT to manipulate. By utilizing tests with high sensitivity and applying sound clinical reasoning, I determined this patient may benefit from manipulation.

      The trigeminal nerve is comprised of 3 branches: ophthalmic, maxillary, and mandibular. The trigemino-cervical nucleus (TCN) consists of the sensory afferent fibers of the C1-3 nerve roots along with the pars caudalis portion of the trigemino nucleus.(1) Thus, the integration of these afferents and the trigeminal nerve into to the pars caudalis is called the TCN. Central sensitization (CS) is a phenomenon when nociceptor inputs can trigger a prolonged but reversible increase in the excitability and synaptic efficacy of neurons in central nociceptive pathways. (2) All 3 branches of the trigeminal nerve can be sensitized thus producing some of the symptoms I mentioned in the original post. Due to hypomobility at the C2/3 ZJ there was aberrant afferent stimuli entering the TCN creating a CS. The repetitive noxious input from the C2/3 ZJ gradually causes CS of the TCN thus potentially creating TSCO. (3-5)

      Thank you once again for your comments and if TSCO makes you want to learn more I recommend you register for the NAIOMT courses!


      1. Busch V, Frese A, Bartsch T. [The trigemino-cervical complex. Integration of peripheral and central pain mechanisms in primary headache syndromes]. Schmerz. 2004;18:404-410.
      2. Woolf C. Central sensitization: Implications for the diagnosis and treatment of pain. Pain. 2011;152:S2-S15.
      3. Watson DH, Drummond PD. Head pain referral during examination of the neck in migraine and tension-type headache. Headache. 2012;52:1226-35.
      4. Vernon H, Sun K, Zhang Y, Yu XM, Sessle BJ. Central Sensitization Induced in Trigeminal and Upper Cervical Dorsal Horn Neurons by Noxious Stimulation of Deep Cervical Paraspinal Tissues in Rats With Minimal Surgical Trauma. J Manipulative Physiol Ther. 2009;32: 506-14.
      5. Goadsby PJ, Knight YE, Hoskin KL. Stimulation of the greater occipital nerve increases metabolic activity in the trigeminal nucleus caudalis and cervical dorsal horn of the cat. Pain. 1997;73:23-8.


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