Cervicogenic dizziness management: Tips from an expert

Cervicogenic dizziness can be tough to manage due to the various potential symptom drivers. Additionally, there can be an overwhelming number of deficits to target, making it difficult to develop a clear, prioritised management plan. In this blog, we’ll outline how expert physiotherapist, Dr. Julia Treleaven, manages this condition.

If you’d like to see how a leading expert manages patients with cervicogenic dizziness, watch Dr. Julia Treleaven’s full Practical here. With Practicals, you can see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster. Learn more HERE.

Assessment overview

After a thorough assessment, we should have an idea of the extent to which the cervical spine is contributing to the patient’s symptoms. If you determine the cervical spine plays no role, the patient needs to be appropriately referred for further assessment.

On the other hand, in mixed cases – that is, where the patient’s symptoms may be both cervicogenic, as well as being caused by another system (e.g. vestibular), improving cervical spine function can enable better participation in rehab targeting those other systems. Importantly, cervical spine dysfunction can be secondary to a primary condition, such as post-concussion visual impairments. In cases like this, we can treat the cervical spine for symptom relief, as well as referring the patient to the appropriate medical professional to address primary impairments.

Lastly, for those patients with primary vestibular dysfunction, treating the neck can assist them to compensate for vestibular impairments by enhancing the function of the cervical spine. In all cases, the patient needs to understand why we are treating the neck and what realistic outcomes we can achieve by doing so.

Treatment overview

Treating cervicogenic dizziness involves a two-pronged approach whereby we focus on improving:

1. Sensorimotor control: sensorimotor dysfunction can drive symptoms including cervical spine pain. To target this, we can retrain balance, cervical proprioception, and head-neck-eye coordination.
2. Cervical afferent input: musculoskeletal dysfunctions such as pain, decreased Range of Motion (ROM), and poor muscular motor control can impair cervical spine afferent input. To address these issues, we can employ manual therapy, motor control training (cervical and scapular), and postural correction.

This blog will be broken down into interventions related to:

• Balance and coordination
• Cervical proprioception training
• Manual therapy
• Postural correction
• Cervical and scapular motor control training

Balance, trunk-head and eye-head coordination

NOTE: During balance and coordination training, we can accept some mild dizziness. However provocation of headaches, nausea or cervical spine pain should be avoided.

Balance

Firstly, for static balance training, we can start a narrow base of support and progress to tandem and single leg stance. Once the patient can manage this, we can add variables such as closing the eyes and standing on a compliant surface. Ultimately, patients should aim to hold any given position for about 30 seconds.

To improve dynamic balance training, we should primarily focus on walking with head turns or nods. This can be progressed to tandem walking as the patient improves.

Trunk-head coordination

Patients can begin training trunk-head coordination by rotating their trunk from side-to-side while keeping their head still and focusing on a point in the mirror in front of them. See Dr. Treleaven demonstrate this exercise in the video below taken from her Practical:

Gaze stabilization

Training gaze stabilization involves the patient maintaining eye focus on a certain point while moving their head. This can involve head rotation, or flexion-extension of the neck depending on the patient’s symptoms. As with trunk-head coordination training, the patient should work up to 2-3 sets of 5 reps for the impaired movement.

Note that some patients with severe symptoms may need to begin training in supine. Eventually, we want to progress into sitting, standing, and possibly even adding gaze stabilization training into static and dynamic balance activities (e.g. tandem stance gaze stabilisation).

Other ways to progress these exercises include increasing movement speed, increasing background activity, or increasing the number of repetitions per set.

Eye-head coordination

To train eye-head coordination, the patient starts seated and uses their index fingers as targets. The exercise involves moving their gaze (eyes only) to the target (index finger), followed by their head. This can be performed for both cervical rotation, and flexion-extension, depending on the patient’s impairments. As with gaze stabilization, we want to work up to 2-3 sets of 5 reps.

Smooth pursuit

Smooth pursuit training requires the patient to follow a target with their eyes. See how Dr Treleaven uses a laser pointer to train smooth pursuit in this video below taken from her Practical:

Cervical proprioception training

We can use joint position error and movement sense training to improve cervical proprioception. Joint position error training involves retraining the ability to identify the head-neck position in space with the eyes closed – Dr. Treleaven demonstrates joint position error training in her Practical, see an example below:

Movement sense training requires the patient to control their head-neck movement by tracing a pattern on the wall in front of them with a laser; the laser is attached to the patient’s head, challenging the ability of the neck to identify, and ‘fine-tune’ its position in space.

Manual therapy

While exercise is the cornerstone treatment for cervicogenic dizziness, manual therapy can reduce pain and restore ROM, thereby improving afferent input to the cervical spine.

The main areas to target are the thoracic spine, cervical spine, and Cervico-Thoracic (C-T) junction. These can be targeted with a number of techniques such as Mobilization With Movement (MWM), Passive Intervertebral Motions (PIVM’s), and Sustained Natural Apophyseal Glides (SNAGs). Importantly, manual therapy techniques should always be followed with exercise prescription to maintain gains achieved in the session.

Postural corrections

Postural correction helps to offload affected structures and train deep stabilizing muscles in functional positions. Note that postural correction is unique to each patient, so the cues for each patient will vary. Dr. Treleaven recommends performing a 10 second hold of any given postural exercise every 15 minutes during the day. While this may not be possible for every patient, our role is collaborating with the patient to create a schedule that suits their needs.

Cervical and scapular motor control training

For motor control training, the initial focus is on achieving excellent movement quality rather than improving strength, endurance, or even full ROM. For these exercises we typically start in positions like supine, quadruped, and side-lying.

Cranio-cervical flexion

Cranio-cervical flexion training typically begins in supine, where the patient practices this isolated movement without activating superficial neck musculature. Once the patient can perform the cranio-cervical flexion “nod” motion they can progress to the use of biofeedback as shown here:

When the patient is competent with biofeedback training, deep neck flexors can be trained concurrently with the larger cervical muscles (e.g. sternocleidomastoid), by adding a slight head lift off the table. Importantly, we want to maintain the cranio-cervical flexion “nod” while performing the head lift. Patients should aim to work up to 2 sets of 10 x 10 second holds.

Cervical extensor training

The ideal position to start training the cervical extensors is in quadruped, which also enables concurrent serratus anterior training. However, prone on elbows or seated forward leaning positions can also be used.

It is important to retrain dysfunctional cervical movements identified in the assessment, such as extension and rotation. Patients should perform 1-2 sets of 5 repetitions for the target movement. Once the patient has mastered these basic cervical spine motions, they can progress to more challenging positions such as a plank.

Scapular motor control

Scapular motor control training begins in side-lying so the patient can focus on isolated scapular muscle activation. We can use a combination of both manual contact by the therapist and palpation by the patient for biofeedback (e.g. palpating their upper trapezius to ensure minimal activation while performing scapular retraction). Once the patient learns this, they should work up to 1-2 sets of 10 x 10 second holds. Scapular motor control training can be progressed by working in an upright position and adding low external loads.

Wrapping Up

Optimal management of cervicogenic dizziness first includes a thorough assessment. Treatment includes addressing both sensorimotor control deficits and improving cervical afferent input. Of course, it is crucial that we educate our patients on how cervical spine treatment fits into their management plan, and what they can expect the outcome to be. Treating this condition is tough, but with this approach you can start treating like the experts.

For an in-depth understanding on how to master your management of cervicogenic dizziness, check out Dr.Treleaven’s Practical here.