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Keith Wobeser, PT, OCS, COMT
MAPS Faculty, Fellow in Training, MAPS Orthopedic Manual Therapy Fellowship 

Chris R Showalter, PT, OCS, COMT, FAAOMPT 
Fellowship Program Director

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Management of Patients with Cervicogenic Dizziness

January 19, 2018

Addison Lerner, DPT, COMT
Fellow in Training
MAPS Accredited Orthopedic Manual Therapy Fellowship

Chris R. Showalter PT, OCS, COMT, FAAOMPT
Fellowship Program Director

Research Commentary

Dizziness is the prevalent compliant in 7% of physician visits by patients over the age of 45 and is the leading reason for physician visits for individuals over 65 (Jung et al., 2017, Reid et al. 2012).  Dizziness can originate from several bodily systems, including dysfunction in musculoskeletal, vestibular, cardiovascular, neurologic, and/or metabolic systems. It is therefore vital to screen appropriately to determine if the patient’s dizziness is amenable to physical therapy management, or whether appropriate referral is required. Clinical assessment and clinical decision making is an essential component of the screening and diagnostic processes, and the subsequent physical therapy management (Jung et al., 2017).

This month’s Research Commentary discusses a recent paper reporting a case series of seven patients diagnosed with cervicogenic dizziness. The paper Clinical Decision Making in Management of Patients with Cervicogenic Dizziness: A Case Series” (Jung et al., 2017) explores the important role of clinical decision making in the management of this disorder. The original article can be found here:

A patient’s reported sensation of “dizziness” can be related to numerous different conditions, including:

1) benign paroxysmal positional vertigo (BPPV)

2) cervicogenic dizziness

3) cervical instability

4) vertebral and carotid arterial insufficiency, and coronary arterial disease (CAD)

5) Meniere’s disease

6) other neurological causes beyond the scope of physical therapy care

Accurate and continuous clinical assessment, clinical reasoning (including lateral thinking), and clinical decision making are hallmark components of Geoff Maitland’s approach to the patient-centric assessment and management of neuro-musculoskeletal disorders. Maitland trained therapists “funnel” subjective and objective clinical data to understand the complex inter-relationships of the nature, stage, severity and stability of the clinical disorder to determine appropriate treatment strategies.

Cervicogenic dizziness (CGD) is defined as “a nonspecific sensation of altered orientation in space and disequilibrium originating from abnormal afferent activity from the neck” (Jung et al., 2017).  The authors note that the pathophysiology of CGD is not fully understood, however it is hypothesized that adverse changes in the proprioceptors in the cervical spine may affect sensorimotor control of gaze stabilization, eye-head movement, and postural stability. CGD can cause nausea, tinnitus, neck pain and stiffness, headache and visual disturbances (Jung et al., 2017, Reid et al., 2012). CGD can stem from a cervicogenic headache (CGH), which represents 14-18% of headaches, and can also cause neck pain and stiffness (Zito et al., 2005).  CGH, like CGD, requires accurate assessment and conservative and manual treatment from therapists, however, clinical decision making and determining appropriate treatment can be challenging as it is primarily based upon the patient’s subjective reporting (Haldeman and Dagenais, 2010). It is worth noting there is no current diagnostic gold standard test for the diagnosis of CDG.

The Jung et al., (2017) Paper in Detail  
Study Methods

Patients were referred to two primary physical therapists. A total of 59 patients presented with dizziness. Of these, 36 presented with BPPV, 13 presented with symptoms consistent with vestibular hypofunction without any musculoskeletal dysfunction, and the remaining 10 presented with complaints of dizziness without clinical signs of vestibular dysfunction accompanying a musculoskeletal dysfunction.

·       Inclusion Criteria - The 7 patients selected presented with neck pain and accompanying subjective symptoms, including dizziness, unsteadiness, visual disturbances, and light headedness.  They were cleared for neurological impairments using various special tests.

·       Exclusion Criteria - Any medical condition that would preclude conservative management of dizziness (such as CAD or hypotension), medical conditions excluding primary manual therapy interventions, (such as progressive cervical myelopathy or acute fracture), and confirmed central or peripheral vestibular disorder. 


Outcome measures included the numeric rating scale which was utilized to measure both dizziness and neck pain (NPRS) independently, the Dizziness Handicap Inventory (DHI), the Patient-Specific Functional Scale (PSFS), and the Global Rating of Change(GROC) 

·         NPRS: an 11-point ordinal scale from 0 (no severity) to 10 (high severity or worst possible pain)

·         DHI: scores range from 0-100, with higher scores indicating progressive disability

·         PSFS: self-report measure of function and activity limitation, 11-point ordinal scale from 0 (unable to perform) to 10 (able to perform activity at preinjury level)

·         GROC: self-reported measure to investigate a patient’s perceived overall improvement or regression over time, 15 point scale from -7 (great deal worse) to +7 (great deal better)


The treatment strategy for each patient addressed relevant impairments and comparable signs and symptoms. Treatments were intended to reduce dizziness by minimizing negative contributing factors associated with musculoskeletal and sensorimotor function.  Treatment included manual therapy with progression to self-mobilizations and integration of functional retraining exercises.  It also included a combination of upper cervical distraction and sub occipital trigger point release, sensorimotor retraining, eye head coordination, and postural balance training.

The Clinical Decision Making Approach

The approach followed a 4 step process (see chart below), informed by current available best evidence, which was utilized in physical therapy management. For the full flow chart in Jung’s approach, please refer to “Clinical Decision Making in Management of Patients with Cervicogenic Dizziness: A Case Series” (Jung et al., 2017).

Jung’s clinical decision-making approach may be summarized as follows:

·         “First Step:       Understanding History and Behavior”

Includes extensive medical history & medication review as part of subjective exam, including characteristics of dizziness symptoms and relationship to cervical dysfunction, whiplash, etc., as well as episodic nature associated with cervical movement or motion sensitivity.

·         “Second Step:  Comparing and Contrasting Clinical Features for                                    Differential Diagnoses”

Includes an exclusion-based diagnostic process along with screening with contraindication and precaution to related examination; reproduction of dizziness and absence of both central & peripheral vestibular disorders; BBPV testing.

·         “Third Step:     Pattern Recognition of CGD”

Includes subjective history of cervical region and temporal relationship, observations during clinical examination of any postural imbalance, relieving factors associated with cervical movement testing, positive signs of specific tests, altered sensorimotor disturbance.

·         “Fourth Step:  Decision of Treatment Strategy”

Determine if trial treatment to cervical region affects cervical dysfunction and dizziness, and/or improvement of abnormal sensorimotor items.  Examine disruption in any other sensory systems with altered proprioception input for potential sensorimotor retraining.


The 7 patients, all female, had a mean age of 57, ranging from 31-86.  They completed PT management for an average of 13 sessions, ranging from 8-30 sessions over a course of 7 weeks. 

1.    Clinically significant improvements were seen at the cessation of treatment in the NPRS for:

- dizziness (mean difference 5.7, 95% confidence interval (CI)),

- neck pain (mean difference 5.4, 95% CI), and

-  the Dizziness Handicap Inventory (mean difference 32.6, 95% CI). 

2.    Patients also demonstrated overall satisfaction via PSFS (mean difference 9) and GROC (mean difference +6).

Study Limitations

1.    The smooth pursuit neck torsion test (SPNT) in patients 3, 4, 5, and 7 was performed in a clinical setting rather than via the instrument-assisted method used in previous studies. This may reduce the level of evidence supporting a non-instrumented SPNT in isolation.

2.    All 7 patients were female, which may bias the results and compromise the generalizability of findings.

3.    Long term follow-up was not performed after the 7 weeks of treatment was completed.  Thus, it is unknown if symptoms returned.

4.    Finally, there was no control group, thus changes in the outcomes cannot necessarily be attributed to the interventions performed.


Clinical decision making for CGD continues to be a challenge, this study described a 4-step structured approach to help guide a decision making process in management of CGD.  However, the paper was unable to demonstrate a cause and effect relationship, despite its statistically significant outcomes.


·       The 4 step clinical approach utilized by Jung et al, (2017) may provide physical therapists with a valuable tool in determining potential treatment strategies for patients with CGD.  Patients reported improvements in both Pain and Dizziness and scores improved on the DHI.  However, in 4 patients, manual interventions and exercises were not sufficient to address all of the sensorimotor deficits exhibited. 

·       Recent studies have shown that joint mobilizations provide a significant impact on overall on both short-term outcomes (at 12 weeks) (Reid et al. 2014) and long-term outcomes (at 52 weeks) (Reid et al. 2015) for dizziness frequency, DHI score, and Global Perceived Effect (GPE). The joint mobilizations utilized in the Reid studies included: 1) Maitland Postero-Anterior Passive Accessory Intervertebal Mobilizations (PAIVMs) and 2) Mulligan sustained natural apophyseal glides (SNAGS). Both mobilizations were found to be equally effective in the management of CGD.

·       Future studies are needed to further explore the clinical decision making process used by therapists treating CGD.  Ideally they should target interventions that treat dizziness, cervical pain and stiffness, combined with balance impairments, and head positioning errors.

Cheers and Enjoy,

Addison Lerner and Chris R. Showalter 

© Maitland-Australian Physiotherapy Seminars

Not to be reproduced, copied or retransmitted in any manner without author's express written permission

Directing others to the MAPS website ( is permissible.

For those interested in exploring more about the assessment and treatment of  Cervicogenic Dizziness, we suggest the MAPS “MT-UC: Upper Cervical Dysfunction Seminar.” Consistent with the Jung 2017 article, MT-UC explores the clinical reasoning, differential assessment, diagnosis and management of CGV, CGH, Tempero-Mandibular dysfunction, BPPV and Concussion.


Jung, F.C., Mathew S., Littman, A.E., Macdonald C.W. (2017). Clinical Decision Making in Management of Patients with Cervicogenic Dizziness: A Case Series. Journal of Orthopedic & Sports Physical Therapy, Vol. 47 (11), 874-884.

Haldeman, S., Dagenais, S. (2010). Choosing a treatment for cervicogenic headache: When? What? How much?. The Spine Journal, 10, 169-171.

Reid, S. A., Rivett, D. A, Katekar, M.G., Callister, R. (2012). Efficacy of manual therapy treatments for people with cervicogenic dizziness and pain: protocol of randomized controlled trial. BMC Musculoskeletal Disorders, 13, (201), 1471-1479.

Reid SA, DA Trencin, Katekar MG, Callister R. (2014) Comparison of Mulligan sustained natural apophyseal and Maitland mobilizations for the treatment of Cervicogenic dizziness: a randomized controlled trial. Physical Therapy 2014 (94) 4: 466-476)

Reid R SA Callister, Snodgrass SJ, Katekar MG, Trencin DA. (2015) Manual therapy for cervicogenic dizziness: Long-term outcomes of a randomized trial. Manual therapy 2015 Feb; (20) 1:148-156

Zito, G., Jull, G., Story, I. (2005). Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache. Manual Therapy, 11, 118-129.

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