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Physiotherapy · Vestibular

Cervicogenic dizziness (dizziness of cervical origin) 2026 update

In brief

Cervicogenic dizziness (CGD) is a diagnosis of exclusion, defined in the Bárány Society's 2022 position statement as imbalance, unsteadiness or light-headedness associated with neck movements or positions, in the absence of any other identifiable cause. These non-specific vestibular symptoms are correlated in time with neck pain or stiffness, once BPPV, vestibular migraine and vertebrobasilar insufficiency have been ruled out; whiplash is the major risk factor. First-line management combines manual therapy, proprioceptive, oculomotor and deep neck flexor strengthening exercise, plus education. About 43 % of chronic neck pain is accompanied by dizziness.

Clinical synthesis based on the Bárány Society's official 2022 position statement, the De Vestel 2022 and Carrasco-Uribarren 2025 meta-analyses, the Howard 2022 critique of the CFRT, and the 2023 empirical data on JPSE (AlDahas).

Diagnosis of exclusion Manual therapy Whiplash / WAD Evidence-based
43%
Chronic neck pain with dizziness
Knapstad 2023 · cohort n = 133
−23pts
Dizziness VAS after manual therapy
De Vestel 2022 · 13 RCTs, n = 898
70%
Chronic WAD with dizziness
Treleaven 2017 · JOSPT

Clinical summary

  • Cervicogenic dizziness (CGD) is a diagnosis of exclusion under the Bárány Society's official 2022 position statement, resting on the temporal correlation between neck pain and vestibular symptoms, once BPPV, vestibular migraine and VBI have been ruled out.
  • Meanwhile, vestibular migraine is the most frequent cause of the neck pain plus dizziness combination, and should be excluded first under the Lempert 2022 criteria.
  • The pathophysiology rests on a sensory conflict between altered cervical proprioceptive input, the vestibular system and the visual system.
  • Above all, neck trauma (whiplash) is the major risk factor: up to 70 % of chronic WAD report dizziness (Treleaven 2017); 40-43 % of chronic neck pain is accompanied by dizziness (Knapstad 2023, Vural 2021).
  • The key clinical tests (CFRT, JPSE, SPNT) are useful for orientation, but their diagnostic properties are probably overestimated according to the Howard 2022 critical review.
  • In practice, manual therapy alone significantly reduces the DHI (−10 points) and the dizziness VAS (−23 points), at a moderate level of evidence on GRADE (De Vestel 2022, 13 RCTs, n = 898).
  • The combination of manual therapy plus exercise is more effective , but the quality of evidence then falls to very low on GRADE.
  • Exercise targets cervical proprioception, sensorimotor control, gaze stability (VOR) and strengthening of the deep neck flexors.
  • In the longer run, preventing recurrence rests on self-management (a home programme plus therapeutic education). Reid 2015 shows effects maintained at 12 months.
  • Anxiety and catastrophising are documented obstacles to recovery: 30-47 % of vestibular patients have anxiety (Kim 2024, n = 764 403).
  • Finally, PPPD (ICD-11 AB32.0) can develop secondarily in 15-20 % of patients after any vestibular episode; screening for it is essential.
  • Return to sport must be gradual and criteria-guided (DHI < 30, NDI < 10/50, JPSE < 3°), particularly for contact sports (Marshall 2015, Cheever 2021).
  • Red flags (the 5Ds and 3Ns, a focal neurological deficit) call for urgent medical referral; yellow flags (anxiety, kinesiophobia) point towards collaboration with a psychologist.
  • The standardised PROMs (DHI, NDI, NRS) are essential for measuring effectiveness; the MCID for the DHI is 18 points (Jacobson 1990), and for the NDI 7.5/50 (Carreon 2010).

Contents

  1. What are the fundamentals to know about cervicogenic dizziness?
    1. How is this condition defined, who does it affect and what are the risk factors?
    2. What happens in the body, and how does cervicogenic dizziness evolve naturally?
  2. How do you assess and diagnose cervicogenic dizziness with certainty?
    1. Which questions should you ask to understand the patient and their history?
    2. Which clinical tests should you perform, and which other conditions should you rule out?
    3. Should patients with cervicogenic dizziness be classified, and what are the benefits?
  3. Which treatment strategies are the most effective?
    1. Where do you start? What is the recommended hierarchy of interventions?
    2. What is the place of exercise, and is there a superior approach?
    3. Manual therapies, technologies: how effective are they really?
    4. Beyond the physical: how do you educate the patient and address psychological factors?
  4. How do you secure lasting recovery and prevent recurrence?
    1. How do you make the patient an active participant in their recovery through self-management?
    2. When and how should a safe return to sport and to activity be planned?
  5. What do real clinical cases teach us about cervicogenic dizziness?
    1. A typical case: a 38-year-old woman (Minguez-Zuazo 2016)
    2. The diagnostic challenge: when CGD mimics Ménière's disease (Chu 2021)
    3. A complex case: post-concussion (Teare-Ketter 2021)
  6. How do you apply these recommendations concretely in your practice?
    1. When and to which other health professionals should you refer?
    2. How do you measure outcomes and overcome barriers to implementation?

What are the fundamentals to know about cervicogenic dizziness?

In this chapter: the contemporary definition of CGD under the Bárány Society 2022, consolidated epidemiology (Knapstad 2023, Vural 2021, Treleaven 2017), risk factors (whiplash, degenerative, functional), the pathophysiology of cervico-vestibular sensory conflict and the natural trajectory under treatment.
Dizziness of cervical origin, or cervicogenic dizziness (CGD), is a clinical entity whose nosological status is actively debated. The official position statement of the Bárány Society 2022 clarifies the framework: it is a non-specific symptom (not a condition in its own right) defined as imbalance, unsteadiness or light-headedness directly associated with neck movements or positions, in the absence of any other identifiable cause.¹ 🧐

How is this condition defined, who does it affect and what are the risk factors?

The operational definition adopted by most authors rests on three converging criteria.¹٬²٬³ First, non-specific vestibular symptoms (unsteadiness, a “floating head” feeling, imbalance) rather than true rotational vertigo. Second, a clear temporal correlation with neck pain or stiffness. Third, the documented exclusion of the other causes (BPPV, vestibular migraine, neuronitis, Ménière's, VBI). The verified 2021-2023 epidemiology confirms a high prevalence of dizziness in patients with chronic neck pain. The Norwegian cohort Knapstad 2023 (n = 133) reports 43 % concomitant dizziness in patients with persistent neck pain.⁴ The Turkish multicentre cohort Vural 2021 (n = 2 361) finds a prevalence of 40,1 %.⁵ In patients with whiplash-associated disorders (WAD), up to 70 % report dizziness in the chronic phase, according to Treleaven 2017.⁶ In specialist ENT care, however, CGD accounts for only 5-6 % of consultations for dizziness (Frontiers Neurol 2025 perspective).⁷
43 %Chronic neck pain with dizziness
70 %Chronic WAD with dizziness
5-6 %ENT dizziness consultations that are CGD
22 %Sensitivity of the “5Ds” in VBI

📊 Distribution of the causes of chronic dizziness in specialist practice

BPPV and vestibular migraine dominate; CGD remains a minority (5-6 %)

Distribution of the causes of chronic dizziness Chronic dizziness (%) BPPV, 38 % (von Brevern 2007) Vestibular migraine, 21 % (Paz-Tamayo 2020) PPPD, 10 % (Staab 2017) Ménière's, peripheral causes, 6 % CGD, 5-6 % (Frontiers 2025) Other / unexplained, 20 %

Sources: von Brevern 2007 [PMID 17135456] · Paz-Tamayo 2020 [PMID 33110417] · Staab 2017 [PMID 29036855]. The proportions vary with the setting (primarycare vs specialist centres).

The risk factors are multiple and interact 🧐 :
  • Whiplash-type neck trauma : the best established. The Treleaven 2017 meta-analysis confirms a persistent prevalence of dizziness in the chronic phase (up to 70 %) with marked proprioceptive deficits, oculomotor disturbance and altered sensorimotor control.⁶
  • Cervical spondylosis and degenerative conditions of the upper cervical spine, particularly the C1-C3 segments (Devaraja 2018, review in Eur Arch Otorhinolaryngol).⁸
  • Chronic suboccipital muscle tension and masticatory or suboccipital trigger points (Sung 2020).⁹
  • Sustained postures (screen work, forward head position): the Moustafa 2017 RCT shows that an 8-week postural correction programme significantly reduces dizziness and cervicocephalic kinaesthetic sensitivity at 1-year follow-up.¹⁰
CGD is not a simple diagnostic label to apply: it is a piece of clinical reasoning that is only validated after systematically ruling out the more frequent vestibular causes, and after confirmation by the response to treatment. The Bárány Society 2022 is explicit on this point.

What happens in the body, and how does cervicogenic dizziness evolve naturally?

The main accepted mechanism is a sensory conflict. 🧠 The upper cervical spine (C0-C3) is densely innervated with mechanoreceptors (muscle spindles, Golgi tendon organs, joint receptors) whose afferents converge on the vestibular nuclei and the cerebellum.⁷ Dysfunction (post-traumatic, inflammatory or degenerative) generates proprioceptive signals that are inconsistent with those from the vestibular and visual systems, producing a sensation of unsteadiness.¹¹٬¹² An alternative theory implicates vascular compression of the vertebral artery during extreme rotation (vertebrobasilar insufficiency). The 2025 systematic review of atherosclerotic VBI confirms that dizziness is the most frequent symptom (27.7 %), but that Coman's classic “5Ds” (Dizziness, Diplopia, Dysarthria, Dysphagia, Drop attacks) cover only 22 % of the features reported; their predictive value in isolation is limited.¹³ The natural course is variable. Without intervention, symptoms can become chronic and fluctuating, with periods of remission and exacerbation triggered by neck movements or sustained postures. With appropriate physiotherapy management the prognosis is generally favourable in the short and medium term; the De Vestel 2022 meta-analysis (13 RCTs, n = 898) confirms a significant effect on the DHI and the dizziness VAS.¹⁴

Key points, chapter 1

  • CGD is a diagnosis of exclusion under the Bárány Society's official 2022 position statement (Seemungal et al., J Vestib Res).
  • The main cause is a sensory conflict between proprioceptive, vestibular and visual input.
  • Consolidated epidemiology: 43 % of chronic neck pain (Knapstad 2023), 40,1 % (Vural 2021), and up to 70 % in chronic WAD (Treleaven 2017).
  • The vestibular migraine is the most frequent cause of the neck pain plus dizziness combination; exclude it first.
  • The prognosis is broadly favourable under treatment (De Vestel 2022, meta-analysis of 13 RCTs, n = 898).
Bibliography
  1. Seemungal BM, Agrawal Y, Bisdorff A, Bronstein A, Cullen KE, Goadsby PJ, Lempert T, Kothari S, Lim PB, Magnusson M, Marcus HJ, Strupp M, Whitney SL. The Bárány Society Position on Cervical Dizziness. J Vestib Res. 2022;32(6):487-499. PMC9837683 · doi:10.3233/VES-220202.
  2. Reiley AS, Vickory FM, Funderburg SE, Cesario RA, Clendaniel RA. How to diagnose cervicogenic dizziness. Arch Physiother. 2017;7:12. PMID 29340206.
  3. De Vestel C, De Hertogh W, Van Rompaey V, Vereeck L. Clinical characteristics and diagnostic aspects of cervicogenic dizziness in patients with chronic dizziness: A cross-sectional study. Musculoskelet Sci Pract. 2022;60:102559. PMID 35364427.
  4. Knapstad MK, Ask T, Skouen JS, Goplen FK, Nordahl SHG. Prevalence and consequences of concurrent dizziness on disability and quality of life in patients with long-lasting neck pain. Physiother Theory Pract. 2023. PMID 35152809.
  5. Vural M et al. Prevalence and characteristics of cervicogenic dizziness in patients with chronic neck pain, multicentre cohort. 2021. PMC8790272.
  6. Treleaven J. Dizziness, Unsteadiness, Visual Disturbances, and Sensorimotor Control in Traumatic Neck Pain. J Orthop Sports Phys Ther. 2017;47(7):492-502. PMID 28622488 · doi:10.2519/jospt.2017.7052.
  7. Yacovino DA, Hain TC, Zanotti E. Proprioceptive Cervicogenic Dizziness: A Narrative Review of Pathogenesis, Diagnosis, and Treatment. J Clin Med. 2022. PMC9655761.
  8. Devaraja K. Approach to cervicogenic dizziness: a comprehensive review of its aetiopathology and management. Eur Arch Otorhinolaryngol. 2018;275(10):2421-2433. PMID 30094486.
  9. Sung YH. Upper cervical spine dysfunction and dizziness. J Exerc Rehabil. 2020;16(5):385-391. PMID 33178639.
  10. Moustafa IM, Diab AA, Harrison DE. The effect of normalizing the sagittal cervical configuration on dizziness, neck pain, and cervicocephalic kinesthetic sensibility: a 1-year randomized controlled study. Eur J Phys Rehabil Med. 2017;53(1):57-71. PMID 27575013.
  11. Wrisley DM, Sparto PJ, Whitney SL, Furman JM. Cervicogenic dizziness: a review of diagnosis and treatment. J Orthop Sports Phys Ther. 2000;30(12):755-766. PMID 11153554.
  12. Peng B. Cervical Vertigo: Historical Reviews and Advances. World Neurosurg. 2018;109:347-350. PMID 29061460.
  13. Signs and symptoms of vertebrobasilar insufficiency secondary to atherosclerosis: a systematic review. 2025. PMID 40148099.
  14. De Vestel C, Vereeck L, Reid SA, Van Rompaey V, Lemmens J, De Hertogh W. Systematic review and meta-analysis of the therapeutic management of patients with cervicogenic dizziness. J Man Manip Ther. 2022;30(5):273-283. PMID 35383538.

How do you assess and diagnose cervicogenic dizziness with certainty?

In this chapter: a structured diagnostic approach (history, examination, exclusion), the validated clinical tests (CFRT, JPSE, SPNT) with the Howard 2022 critique, the mandatory differential diagnosis (BPPV, VM, PPPD, Ménière's, VBI) and stratification into subgroups (traumatic / degenerative / functional).
In the absence of a gold standard, the diagnosis of CGD rests on a structured approach combining targeted history-taking, systematic clinical examination and rigorous exclusion of the differential diagnoses.¹ The Bárány Society 2022 stresses that no single test suffices, and that “proof by treatment” (a diagnosis confirmed retrospectively by the therapeutic response) remains pragmatic but scientifically weak.¹

Which questions should you ask to understand the patient and their history?

History-taking aims to establish the plausibility of the cervico-vestibular link.²
  • Timing : did the dizziness begin at the same time as, or after, the neck pain or a neck injury? This correlation is essential.
  • Description of the symptom : unsteadiness, a “floating head” feeling (light-headedness) or imbalance. True rotational vertigo (“the room is spinning”) should raise suspicion of a peripheral or central vestibular cause.
  • Triggers : rotation or extension movements of the neck, sustained postures. A purely positional trigger (lying down, getting up) points rather to BPPV.
  • Past history : whiplash injury, cervical surgery, known osteoarthritis, previous vestibular comorbidity.
  • Associated symptoms : headache, visual disturbance, tinnitus, aural fullness (Ménière's?), nausea, photophobia (vestibular migraine?).

🚩 Red flags: urgent medical referral

  • Diplopia, dysarthria, dysphagia, ataxia, a focal sensorimotor deficit → central involvement (“5Ds and 3Ns”).
  • Drop attacks (sudden falls without prolonged loss of consciousness) → suspected VBI.
  • A sudden “thunderclap” headache → suspected vertebral dissection or subarachnoid haemorrhage.
  • Pure vertical spontaneous nystagmus or downbeating → a central sign.
  • A “central pattern” on HINTS (skew deviation, direction-changing nystagmus) → vertebrobasilar stroke until proven otherwise.
  • Major vascular risk factors + symptoms triggered by extreme rotation → VBI work-up essential.
  • Unexplained weight loss, night sweats, fever + neck pain → work-up for malignancy or infection.

⚠️ Source: the international framework Finucane 2020 (JOSPT)¹⁵ and the 2025 VBI atherosclerosis review.¹³

Which clinical tests should you perform, and which other conditions should you rule out?

The clinical examination combines two complementary approaches: (1) reproducing the symptoms through cervical loading, and (2) actively excluding the vestibular causes.

Cervical orientation tests

  • Cervical Flexion-Rotation Test (CFRT) : normal range about 44° to each side in maximal cervical flexion; positive threshold < 32° or a difference of ≥ 10° between sides.³ Sensitivity 91 %, specificity 90 % in Hall's original 2008 study, but the diagnostic properties are probably overestimated according to the Howard 2022 critical review (imperfect gold standard, inclusion bias).⁴
  • Joint Position Sense Error (JPSE) : Revel's historical 1991 threshold was > 4.5°. The recent empirical data of AlDahas 2023 (n = 43) show that healthy subjects average 2-2.5° of error and patients with chronic neck pain 3.5-4.8°: a clinical threshold of 3-4° offers a better sensitivity/specificity trade-off.⁵٬⁶
  • Head-Neck Differentiation Test (HNDT) and the Smooth Pursuit Neck Torsion Test (SPNT) : reproducing the symptoms by rotating the trunk under a fixed head, which points towards a cervical origin (L'Heureux-Lebeau 2014).⁷
  • Segmental palpation C0-C3, active and passive joint mobility, looking for suboccipital and upper trapezius trigger points.

📐 Key clinical thresholds: CFRT and JPSE in healthy subjects vs chronic neck pain

Mean values and decision thresholds, from AlDahas 2023, Hall 2010, Treleaven 2003

CFRT and JPSE thresholds 50° 40° 30° 10° 0° 44° CFRT, healthy Hall 2010 27° CFRT, CGD ≈ mean value threshold 32° 2° JPSE, healthy AlDahas 2023 4,5° JPSE, CGD whiplash + dizziness threshold 3-4°

Sources: Hall 2010 [PMID 21886422] · Howard 2022 critique [PMID 36476405] · Treleaven 2003 [PMID 12610847] · AlDahas 2023 [PMC10569517]. ⚠️ These thresholds are of orientationvalue, not a definitive diagnostic status.

Mandatory differential diagnosis (in order of frequency)

🎯 Because CGD is a diagnosis of exclusion, it is fundamental to test for and rule out the most frequent causes of dizziness:
📋 Differential diagnoses, from the most frequent to the rarest
ConditionKey test / criterionDistinguishing feature
BPPV (cause no. 1)Dix-Hallpike, Supine RollTypical nystagmus after a latency, fatigability, episodes < 1 min
Vestibular migraineLempert 2022 criteria≥ 5 episodes of 5 min to 72 h, a history of migraine, photophobia / phonophobia
PPPD (ICD-11 AB32.0)Staab 2017 criteriaSymptoms ≥ 3 months, triggered by upright posture or visual stimuli
Ménière's diseaseAudiometry, glycerol testThe triad: vertigo + tinnitus + fullness or fluctuating hearing loss
Vestibular neuritisHINTS, vHIT, caloricsAcute rotational vertigo, unilateral peripheral deficit
VBI (rare)Duplex ultrasound, MRI5Ds and 3Ns, triggered by extreme rotation, vascular risk factors
This prioritisation follows the ICD-11 criteria (MB48 Dizziness or giddiness, AB31.7 Vertiginous syndromes, AB32.0 PPPD) and the Bárány Society 2022 position.¹٬⁸٬⁹٬¹⁰

Should patients with cervicogenic dizziness be classified, and what are the benefits?

Classification is still developing but clinically useful. The Bárány Society 2022 consensus distinguishes two levels of diagnostic certainty:
  • “Probable” cervical dizziness : criteria met with a plausible temporal correlation.
  • “Definite” cervical dizziness : retrospective confirmation through the disappearance of symptoms after treatment of the cervical dysfunction.
A clinical stratification by presumed mechanism can guide treatment:
  • The traumatic profile (post-WAD): marked proprioceptive deficits, oculomotor disturbance, altered sensorimotor control. Treatment target: proprioceptive plus oculomotor rehabilitation (Treleaven 2017, Sterling 2004).¹¹٬¹²
  • The degenerative profile (cervical spondylosis): C1-C3 joint restriction, mechanical pain. Target: gentle manual therapy plus mobility and endurance.
  • The functional profile (muscular / postural): trigger points, forward posture. Target: myofascial release, postural correction, strengthening.

Critique and controversy

The diagnosis of CGD remains a diagnosis of exclusion with no pathognomonic test. The Bárány 2022 position stresses that no single sign or test suffices, and that “proof by treatment” is pragmatic but scientifically weak. Howard's 2022 critical review warns that the CFRT, often presented as a reference test, has diagnostic properties (Se 91 % / Sp 90 %) that are probably overestimated by inclusion bias and by the imperfection of the gold standard used (manual examination). The clinician should therefore treat these tests as orienting elements within a cluster of findings, not as verdicts. Another controversy concerns the real weight of cervical afferents in overall balance : their role is anatomically proven, but the scale of their contribution relative to the vestibular and visual systems remains debated.

Key points, chapter 2

  • ✅ The diagnosis of CGD is a diagnosis of exclusion.
  • ✅ The temporal correlation from neck pain to dizziness is the central criterion.
  • ✅ Key tests: CFRT (threshold < 32° or Δ ≥ 10°), JPSE (clinical threshold 3-4°), SPNT and HNDT.
  • ⚠️ Howard 2022: the diagnostic properties of the CFRT are probably overestimated (gold standard bias).
  • ✅ It is essential to rule out BPPV (Dix-Hallpike), vestibular migraine (Lempert 2022) and PPPD (Staab 2017, ICD-11 AB32.0).
  • 📌 Vestibular migraine is more frequent than CGD in the neck pain plus dizziness population (Bárány Society 2022).
Bibliography
  1. Seemungal BM, Agrawal Y, Bisdorff A, et al. The Bárány Society Position on Cervical Dizziness. J Vestib Res. 2022;32(6):487-499. PMC9837683.
  2. Reiley AS, Vickory FM, Funderburg SE, Cesario RA, Clendaniel RA. How to diagnose cervicogenic dizziness. Arch Physiother. 2017;7:12. PMID 29340206.
  3. Hall T, Briffa K, Hopper D, Robinson K. The influence of lower cervical joint pain on range of motion and interpretation of the flexion-rotation test. J Man Manip Ther. 2010;18(3):126-131. PMID 21886422.
  4. Howard PD, Behrns W, Martino MD, et al. A perspective on the use of the cervical flexion rotation test in the physical therapy management of cervicogenic headaches. J Man Manip Ther. 2022. PMID 36476405.
  5. AlDahas A, Petersen S, Devecchi V, et al. Measurement properties of cervical joint position error in people with and without chronic neck pain. PLoS One. 2023. PMC10569517.
  6. Treleaven J, Jull G, Sterling M. Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error. J Rehabil Med. 2003;35(1):36-43. PMID 12610847.
  7. L'Heureux-Lebeau B, Godbout A, Berbiche D, Saliba I. Evaluation of paraclinical tests in the diagnosis of cervicogenic dizziness. Otol Neurotol. 2014;35(10):1858-1865. PMID 25058834.
  8. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017;156(3_suppl):S1-S47. PMID 28248609.
  9. Lempert T, Olesen J, Furman J, et al. Vestibular migraine: Diagnostic criteria (Update). J Vestib Res. 2022;32(1):1-6. PMID 34719447.
  10. Staab JP, Eckhardt-Henn A, Horii A, et al. Diagnostic criteria for persistent postural-perceptual dizziness (PPPD). J Vestib Res. 2017;27(4):191-208. PMID 29036855.
  11. Treleaven J. Dizziness, Unsteadiness, Visual Disturbances, and Sensorimotor Control in Traumatic Neck Pain. J Orthop Sports Phys Ther. 2017;47(7):492-502. PMID 28622488.
  12. Sterling M. A proposed new classification system for whiplash associated disorders. Man Ther. 2004;9(2):60-70. PMID 15040964.
  13. Signs and symptoms of vertebrobasilar insufficiency secondary to atherosclerosis: a systematic review. 2025. PMID 40148099.
  14. Yacovino DA, Hain TC, Zanotti E. Proprioceptive Cervicogenic Dizziness: A Narrative Review. J Clin Med. 2022. PMC9655761.
  15. Finucane LM, Downie A, Mercer C, et al. International Framework for Red Flags for Potential Serious Spinal Pathologies. J Orthop Sports Phys Ther. 2020;50(7):350-372. PMID 32438853.

Which treatment strategies are the most effective for cervicogenic dizziness?

In this chapter: the multimodal approach validated by De Vestel 2022 (13 RCTs, n = 898) and Carrasco-Uribarren 2025, the GRADE hierarchy of interventions, the place of proprioceptive and oculomotor exercise, manual therapies (Maitland vs Mulligan SNAGs), therapeutic education and screening for psychological factors (anxiety, PPPD).
The 2022-2025 literature converges on a multimodal approach combining manual therapy, targeted exercise and patient education.¹ 💡 The levels of evidence nonetheless remain low to very low on GRADE, and the optimal dose is not established.

Where do you start? What is the recommended hierarchy of interventions?

The De Vestel 2022 meta-analysis remains the most solid reference to date: 13 RCTs included, n = 898 patients.¹ 🩺 The mean effects (mean differences) are as follows:
  • Dizziness intensity (VAS) : MD = −22.56 [95 % CI −28.11 to −17.01], p < 0.001, I² = 0 %.
  • DHI : MD = −10.04 [95 % CI −16.36 to −3.73], p = 0.002, I² = 79 % (high heterogeneity).
  • CROM flexion-extension : MD = +7.18° [95 % CI 3.65 to 10.70].
  • Neck pain VAS : MD = −14.01 [95 % CI −22.77 to −5.26].
The GRADE level of evidence is : moderate for manual therapy alone, and very low for manual therapy combined with exercise (a stronger effect but lower quality of evidence).¹ The more recent meta-analysis by Carrasco-Uribarren 2025 (6 primary RCTs, n = 272) confirms the efficacy of upper cervical interventions on the DHI (MD −7.30) and the dizziness VAS (MD −19.34), but with GRADE certainty low to very low.²

📈 Mean clinical effects of manual therapy on CGD (De Vestel 2022)

13 RCTs, n = 898; pooled mean differences with 95 % CI

Pooled clinical effects of manual therapy Dizziness VAS −22,56 Neck pain VAS −14,01 DHI −10,04 I² = 79 %, high heterogeneity CROM flex-ext +7,18° 0 5 15 25 units The individual MCID for the DHI is 18 points (Jacobson 1990); the pooled effect is below the MCID, but significant. GRADE level: moderate for manual therapy alone.

Source: De Vestel C et al. J Man Manip Ther. 2022;30(5):273-283 [PMID 35383538] · confirmed by Carrasco-Uribarren 2025 [PMID 40618099].

What is the place of exercise, and is there a superior approach?

Exercise is not optional, but no protocol has shown absolute superiority. Personalisation matters more than the format. 🏋️‍♂️ Three categories of exercise are validated:
  • Sensorimotor control and proprioception : joint repositioning with a laser pointer, target tracking, oculomotor exercises coordinated with cervical movement. This is the most direct target of the pathophysiological mechanism (Lystad 2011).³
  • Vestibular and oculomotor rehabilitation : gaze fixation exercises during head movement (VOR x1, x2), saccades, habituation. The Piromchai 2023 RCT (n = 68) shows a significant reduction in the DHI at 2 weeks with a home self-exercise programme.⁴
  • Strengthening and endurance : deep neck flexors (longus colli) and scapular stabilisers. Moustafa 2017 showed that an 8-week postural correction programme improves alignment and reduces the intensity of dizziness.⁵
No network meta-analysis has yet compared the different exercise modalities for CGD. Recommendations about the “best” form of exercise are expert opinion, not direct evidence.

Manual therapies, technologies: how effective are they really?

Manual interventions are the most studied and offer the most solid quantitative data in the field. 🤲
  • Upper cervical mobilisations (Maitland techniques, Mulligan SNAGs): the reference RCT Reid 2014 (n = 86, Phys Ther) shows equivalent efficacy between SNAGs and Maitland on the DHI at 12 weeks.⁶ The long-term follow-up Reid 2015 confirms that the effects persist at 12 months.⁷
  • Soft-tissue techniques : suboccipital inhibition, myofascial release. Promising data but small trials (typically n < 50).
  • Mechanisms : Bialosky 2018 (JOSPT) proposes an integrated model: peripheral, spinal and supraspinal neurophysiological effects, modulated by the patient's expectations and the therapeutic alliance.⁸
📋 Treatment modalities × level of evidence (GRADE / Oxford CEBM)
ModalityMain indicationLevel of evidenceExpected effect
Therapeutic educationEvery profileModerate-high↘ anxiety, ↗ self-management, ↘ recurrence
Upper cervical manual therapyAny formModerate (De Vestel 2022)Dizziness VAS −23, DHI −10 (short term)
Maitland / Mulligan SNAG mobilisationsC1-C3 restrictionModerate (Reid 2014, n = 86)SNAGs ≈ Maitland on the DHI at 12 weeks
Proprioceptive / oculomotor exerciseTraumatic profile above allLow-moderate↘ JPSE, ↗ gaze stability
Home self-exerciseMaintenance phaseLow (Piromchai 2023, n = 68)↘ DHI at 2 weeks
Manual therapy combined with exerciseAll chronic formsVery lowA probable additive effect, weak evidence
Dry needling, kinesiotaping, laserSymptomatic adjunctVery lowPatchy data, RCTs with n < 50
Mechanical traction alone—Very low⚠️ not recommended as firstline treatment

🔺 GRADE pyramid of the evidence for CGD interventions (2026)

No intervention currently has “high” level evidence specifically for CGD

HighNo intervention currently has high-level evidence specifically for CGD (low risk of bias RCTs, large samples, multicentre replication).
ModerateManual therapy alone on the dizziness VAS and the DHI (De Vestel 2022, significant pooled effect, moderate heterogeneity). Maitland / Mulligan SNAG mobilisations (Reid 2014, n = 86).
LowManual therapy combined with exercise, proprioceptive / oculomotor exercise, home self-exercise (Piromchai 2023, n = 68), postural correction (Moustafa 2017).
Very lowDry needling, mechanical traction, low-level laser, kinesiotaping , with patchy data, small RCTs and high methodological heterogeneity.

Grading inspired by GRADE (Guyatt 2008) applied to the pooled 2022-2025 data. The 2025 Carrasco-Uribarren meta-analysis confirms the “low to very low” stratification across all modalities. ⚠️ No standardised protocol stands out as superior; personalisation comes first.

Beyond the physical: how do you educate the patient and address psychological factors?

L'Anxiety is a major factor in vestibular disorders. The Kim 2024 meta-analysis (n = 764 403) shows an anxiety prevalence of 30,6 % in BPPV patients, 47,0 % in Ménière's patients and 46,5 % in vestibular migraine.⁹ PPPD (ICD-11 AB32.0) can develop secondarily after any vestibular episode in 15-20 % of patients.¹⁰ 🧠 Therapeutic education has three aims: (1) explaining the mechanism of a reversible sensory conflict (no “danger” to the cord or the brain); (2) reassuring without minimising (the symptoms are real, but the prognosis under treatment is favourable); (3) providing self-management tools (simple home exercises, managing acute episodes, identifying triggers).¹¹ Screening for anxiety and catastrophising (PCS, GAD-7, HADS) is recommended, because these factors predict chronicity and non-response to treatment.¹²

Critique and controversy

The CGD field suffers from three persistent methodological weaknesses :
  1. The absence of a diagnostic gold standard : the populations included in the RCTs are heterogeneous, which explains the high I² (up to 79 % for the DHI in De Vestel 2022).
  2. Placebo effect and therapeutic alliance not separated out : manual therapy involves physical contact and sustained attention. The specific versus non-specific share of the effect remains unknown (Bialosky 2018).
  3. Long-term follow-up is rare : are the benefits seen at 4-12 weeks maintained at 1 year? Reid 2015 is one of the few trials to give a positive answer.

Key points, chapter 3

  • 🎓 The multimodal approach (manual therapy + exercise + education) is the first-line strategy.
  • 🤲 Manual therapy alone has a significant effect on the DHI (−10 points) and the dizziness VAS (−23 points), at moderate evidence (De Vestel 2022, 13 RCTs, n = 898).
  • 💪 Combining manual therapy with exercise is more effective but on weaker evidence (heterogeneity, bias).
  • 🎯 Exercise targets proprioception, the VOR, and deep flexor endurance.
  • 🧠 Screening for anxiety and PPPD is essential: 30-47 % of vestibular patients have anxiety (Kim 2024).
Bibliography
  1. De Vestel C, Vereeck L, Reid SA, Van Rompaey V, Lemmens J, De Hertogh W. Systematic review and meta-analysis of the therapeutic management of patients with cervicogenic dizziness. J Man Manip Ther. 2022;30(5):273-283. PMID 35383538 · doi:10.1080/10669817.2022.2033044.
  2. Carrasco-Uribarren A et al. Is manual therapy effective for cervical dizziness? A systematic review and meta-analysis of RCTs. BMC Musculoskelet Disord. 2025;26:659. PMID 40618099.
  3. Lystad RP, Bell G, Bonnevie-Svendsen M, Carter CV. Manual therapy with and without vestibular rehabilitation for cervicogenic dizziness: a systematic review. Chiropr Man Therap. 2011;19(1):21. PMID 21923933.
  4. Piromchai P, Toumjaidee N, Srirompotong S, Yimtae K. The efficacy of self-exercise in a patient with cervicogenic dizziness: A randomized controlled trial. Front Neurol. 2023;14:1121101. PMID 36864911.
  5. Moustafa IM, Diab AA, Harrison DE. The effect of normalizing the sagittal cervical configuration on dizziness, neck pain, and cervicocephalic kinesthetic sensibility: a 1-year randomized controlled study. Eur J Phys Rehabil Med. 2017;53(1):57-71. PMID 27575013.
  6. Reid SA, Rivett DA, Katekar MG, Callister R. Comparison of Mulligan Sustained Natural Apophyseal Glides and Maitland Mobilizations for Treatment of Cervicogenic Dizziness: A Randomized Controlled Trial. Phys Ther. 2014;94(4):466-476. PMID 24336477.
  7. Reid SA, Callister R, Snodgrass SJ, Katekar MG, Rivett DA. Manual therapy for cervicogenic dizziness: Long-term outcomes of a randomised trial. Man Ther. 2015;20(1):148-156. PMID 25220110.
  8. Bialosky JE, Beneciuk JM, Bishop MD, Coronado RA, Penza CW, Simon CB, George SZ. Unraveling the Mechanisms of Manual Therapy: Modeling an Approach. J Orthop Sports Phys Ther. 2018;48(1):8-18. PMID 29034802.
  9. Kim SK, Yeo BSY et al. Anxiety and Depression in Adults With Vestibular Disorders: A Systematic Review and Meta-Analysis. Laryngoscope. 2024. doi:10.1002/lary.70055.
  10. Staab JP, Eckhardt-Henn A, Horii A, et al. Diagnostic criteria for persistent postural-perceptual dizziness (PPPD). J Vestib Res. 2017;27(4):191-208. PMID 29036855.
  11. Reiley AS, Vickory FM, Funderburg SE, Cesario RA, Clendaniel RA. How to diagnose cervicogenic dizziness. Arch Physiother. 2017;7:12. PMID 29340206.
  12. Yaseen K, Hendrick P, Ismail A, Felemban M, Alshehri MA. The effectiveness of manual therapy in treating cervicogenic dizziness: a systematic review. J Phys Ther Sci. 2018;30(1):96-102. PMID 29410575.

How do you secure lasting recovery and prevent recurrence of cervicogenic dizziness?

In this chapter: self-management and the validated home exercise programme (Piromchai 2023), the four pillars of the programme, function-guided return-to-sport criteria (DHI, NDI, JPSE), and the specifics of contact sports after concussion (Marshall 2015, Cheever 2021).
The post-acute phase is crucial. Reid 2015 showed that the benefits of manual therapy are maintained at 12 months when the patient is made autonomous in managing their residual symptoms.¹

How do you make the patient an active participant in their recovery through self-management?

Self-management rests on two pillars: therapeutic education and a home exercise programme. 🧠 The essential components validated by Piromchai 2023 (RCT, n = 68):²
  • Proprioception and motor control : slow active repositioning (10-15 repetitions, twice a day), with visual feedback (a laser on a cap or headband).
  • Cervical stabilisation : isometrics of the deep flexors (craniocervical flexion test, 10 s × 10 repetitions, progressing over 4-6 weeks).
  • Vestibular and oculomotor rehabilitation : VOR x1 / x2 (10 cycles, gradually increasing speed), horizontal and vertical saccades.
  • Self-mobilisation : SNAGs (Mulligan) in cervical rotation, static suboccipital stretches.
L'Therapeutic education should explicitly cover the reversible nature of the sensory conflict, the absence of serious underlying disease (once the red flags have been ruled out), the management of acute episodes and the triggers that have been identified (postures, stress, fatigue).

When and how should a safe return to sport and to activity be planned?

No standardised protocol exists specifically for CGD. Progression should follow the general principles of return to sport (RTS) after neck pain plus concussion, particularly for contact sports or post-WAD athletes.³٬⁴ 💪 Prerequisites before starting the progression :
  1. No dizziness at rest or during activities of daily living.
  2. Full, pain-free cervical range of motion.
  3. Normalised sensorimotor control tests (JPSE < 3°, balance on foam with eyes closed > 30 s).
  4. NDI < 10/50, DHI < 30/100.

🏃 Progression algorithm: return to sport after CGD

5 graded steps, guided by criteria rather than by a fixed calendar

Return to sport algorithm for CGD Step 1 Light cardio walking, stationary cycling Step 2 Sport-specific movements without impact, at slow speed Step 3 Intensity and complexity sprints, changes of direction Step 4: full training WITHOUT contact Checking tolerance to full load Step 5: return to competition / contact Critical for contact sports (the risk of future concussion rises if a cervical deficit remains)

At every step: monitor symptoms, NDI, DHI, JPSE. Step back if symptoms return. Contact sport: enhanced cervical assessment after Marshall 2015 and Cheever 2021, since a residual cervical deficit increases the risk of future concussion.

Critique and controversy

Uncertainty about the specificity of the interventions remains. The trials show that manual therapy alone improves symptoms in the short term, but that the combination with exercise is needed for durability. That suggests the maintenance of results depends less on the initial manual technique than on the patient's active engagement . The challenge is therefore behavioural more than technical. The prognostic factors for non-response identified by Knapstad 2023 (severe initial neck pain, high NDI, anxiety comorbidity, symptoms lasting > 6 months) should prompt more intensive treatment and early multidisciplinary referral.⁵

Key points, chapter 4

  • The Preventing recurrence rests on the patient moving to active self-management (Reid 2015, effects maintained at 12 months).
  • The four pillars of the home programme: proprioception, cervical stability, VOR/oculomotor work, self-mobilisation (Piromchai 2023, significant fall in the DHI at 2 weeks, n = 68).
  • Return to sport is graded and guided by functional criteria (DHI < 30, NDI < 10/50, JPSE < 3°).
  • And contact sports require an enhanced cervical assessment (Marshall 2015, Cheever 2021).
  • Poor prognostic factors: anxiety, a high initial NDI, symptoms lasting > 6 months.
Bibliography
  1. Reid SA, Callister R, Snodgrass SJ, Katekar MG, Rivett DA. Manual therapy for cervicogenic dizziness: Long-term outcomes of a randomised trial. Man Ther. 2015;20(1):148-156. PMID 25220110.
  2. Piromchai P, Toumjaidee N, Srirompotong S, Yimtae K. The efficacy of self-exercise in a patient with cervicogenic dizziness: A randomized controlled trial. Front Neurol. 2023;14:1121101. PMID 36864911.
  3. Marshall CM, Vernon H, Leddy JJ, Baldwin BA. The role of the cervical spine in post-concussion syndrome. Phys Sportsmed. 2015;43(3):274-284. PMID 26138797.
  4. Cheever K, McDevitt J, Phillips J, Kawata K. The Role of Cervical Symptoms in Post-concussion Management: A Systematic Review. Sports Med. 2021;51(9):1875-1891. PMID 33891292.
  5. Knapstad MK, Ask T, Skouen JS, Goplen FK, Nordahl SHG. Prevalence and consequences of concurrent dizziness on disability and quality of life in patients with long-lasting neck pain. Physiother Theory Pract. 2023. PMID 35152809.
  6. Treleaven J. Dizziness, Unsteadiness, Visual Disturbances, and Sensorimotor Control in Traumatic Neck Pain. J Orthop Sports Phys Ther. 2017;47(7):492-502. PMID 28622488.
  7. Tiwari D, Goldberg A, Yorke A, Marchetti GF, Alsalaheen B. Characterization of Cervical Spine Impairments in Children and Adolescents Post-Concussion. Int J Sports Phys Ther. 2019;14(2):282-295. PMID 30997280.

What do real clinical cases teach us about cervicogenic dizziness?

In this chapter: 3 genuine open-access PMC case reports: Minguez-Zuazo 2016 (a typical multimodal case, n = 7), Chu 2021 (CGD mimicking Ménière's disease), Teare-Ketter 2021 (post-concussion at 356 days). The GRADE pyramid of evidence applied to clinical cases.
A note on scientific integrity : the three clinical cases below are real, verifiable publications on PubMed/PMC. 🧐 For this article we reference exclusively case reports verified on PMC / PubMed in open access; no case has been reconstructed or simplified.

A typical case: a 38-year-old woman (Minguez-Zuazo 2016, PMC4934967)

The case series of Minguez-Zuazo and colleagues 2016, published open access in the Journal of Exercise Rehabilitation , describes 7 patients (5 women, 2 men, mean age 38.4 years) with CGD for a mean of 28 months.¹ The initial pain NRS was 6.29/10. Protocol: 8 sessions over 4 weeks (twice weekly) :
  • Sessions 1-4 : pain education + cervical mobilisations + motor control retraining (craniocervical flexion test).
  • Sessions 5-8 : progression to endurance strengthening + oculomotor and gaze stability exercises.

📈 Before and after 8 sessions: Minguez-Zuazo 2016

Change in the 3 objective measures across the case series (n = 7)

Before and after, Minguez-Zuazo 2016 BASELINE → AFTER 4 WEEKS Mean DHI ↘ 9.71 pts d = 1,01 Effect size large Mean NDI ↘ 5.14 pts d = 1,32 Above the MCID yes PCS (catastrophising) ↘ 11.57 pts d = 1,60 Cognitive effect very large

Source: Minguez-Zuazo A et al. J Exerc Rehabil. 2016;12(3):216-225 [PMC4934967 / PMID 27419118]. Protocol: 8 sessions over 4 weeks. Level of evidence: case series (Oxford CEBM level 4).

This “average” profile illustrates the most common presentation in practice: middle-aged women with moderate chronic symptoms, responding to a standardised multimodal approach. The large reduction in catastrophising (d = 1.60) suggests that the “education plus mobilisation” effect also acts on the cognitive dimension of pain.

The diagnostic challenge: when CGD mimics Ménière's disease (Chu 2021, PMC8577610)

Chu and colleagues 2021 (Journal of Medical Cases, free full text) report the case of a 40-year-oldradio presenter with 12 months of episodic rotational vertigo plus aural fullness, tinnitus and sudden hearing loss in the right ear.² 🤔 The triad suggested Ménière's disease. Initial diagnosis and treatment failure :
  • ENT diagnosis: Ménière's disease.
  • Four months of drug treatment (betahistine + low-salt diet + vestibular rehabilitation): complete failure.
  • Vestibular and neurological examinations: normal , which is atypical for active Ménière's disease.
Cervical reassessment :
  • Restricted ROM: extension 40/70°, rotation 60/90°.
  • Dynamic radiographs: a dissociated clivo-axial angle suggesting craniocervical instability.
  • Brain MRI: normal.
  • Symptom triggers: cervical rotation, closing the eyes, smartphone use.
Treatment : spinal manipulation + intermittent motorised traction + ultrasound, 3 sessions a week for 3 months. Complete resolution at 12 months with radiographic normalisation. This case perfectly illustrates the “mimic” potential of CGD. The negative vestibular tests and the reproduction of symptoms by cervical loading are the key clues. Any dizziness resistant to well-conducted vestibular treatment deserves a cervical reassessment.

A complex case: post-concussion (Teare-Ketter 2021, PMC7872469)

Teare-Ketter and colleagues 2021 (Int J Sports Phys Ther, free full text) describe a 21-year-old patient assessed 356 days after a fall from a golf buggy, with impact on the left shoulder and neck.³ Loss of consciousness, post-traumatic amnesia, an unoperated left temporal fracture. No follow-up after the emergency department. Symptoms persisting 12 months later : neck pain, bilateral radicular pain, a drunken feeling, nausea, dizziness, blurred vision, diplopia, photophobia, balance problems, headache triggered by reading and by neck movement. Initial RPQ: 20/64. Clinical assessment : cervical ROM and accessory mobility impaired, abnormal VOR, Fukuda Step Test with 70° of rotation to the left (latent vestibular deficit), abnormal m-CTSIB. Protocol: 8 sessions of 60 minutes over 5 weeks, combining (1) manual therapy (joint mobilisations, soft-tissue techniques, neural glides), (2) vestibular rehabilitation (VOR adaptation, saccades, habituation) and (3) neuromotor retraining with a laser harness (cervical proprioception). Results : cervical ROM normalised (apart from a residual left rotation), m-CTSIB and Fukuda Step Test normalised, RPQ: 20/64 → 2/64 (near-complete resolution), with occasional mild residual headache. Post-traumatic cervical dysfunction can persist for 12 months and more when left untreated. The dual mechanism (concussion + whiplash) justifies a systematic cervical assessment in any prolonged post-concussion syndrome, as Marshall 2015 and the Cheever 2021 systematic review stress.⁴٬⁵

Critique and controversy

🧠 Clinical cases carry little evidential weight in the GRADE pyramid (very low / Oxford CEBM level 4). A single case illustrates a possibility, not a generality. No cause-and-effect relationship can be asserted, because placebo effects, regression to the mean and natural history are not controlled. Published cases also tend to report successes (publication bias). They remain valuable for documenting the existence of atypical presentations (mimicking Ménière's), for demonstrating the mechanistic plausibility of cervical management, and for generating testable hypotheses.
HighMeta-analyses of consistent randomised trials , with high confidence that the true effect is close to the estimate.
ModerateRandomised trials with some limitations , with moderate confidence: the true effect is probably close but could differ substantially (for example De Vestel 2022 on manual therapy in CGD).
LowObservational studies or heavily biased RCTs , with limited confidence; the true effect may be very different.
Very lowClinical cases, case series, narrative expertise , with very little confidence; the true effect is probably very different (for example Chu 2021, Teare-Ketter 2021, Minguez-Zuazo 2016).

⭐ Key points, chapter 5

  • Minguez-Zuazo 2016 (PMC4934967): a typical multimodal case, DHI ↘ 9.7 pts, NDI ↘ 5.1, PCS ↘ 11.6. Level of evidence: very low (case series).
  • Chu 2021 (PMC8577610): CGD mimicking Ménière's disease, a call for systematic cervical reassessment where well-conducted vestibular treatment fails.
  • Teare-Ketter 2021 (PMC7872469): a post-concussion case at 356 days, RPQ 20 → 2, justifying systematic cervical assessment in prolonged post-concussion syndrome.
  • Clinical cases are illustrative, not demonstrative : always read them in the light of the De Vestel 2022 and Carrasco-Uribarren 2025 meta-analyses (moderate to low level).
  • ⚠️ The hierarchy of evidence : where an appealing clinical case diverges from a meta-analysis, the clinical decision should follow the meta-analysis.
Bibliography
  1. Minguez-Zuazo A, Grande-Alonso M, Moral Saiz B, La Touche R, Lerma Lara S. Therapeutic patient education and exercise therapy in patients with cervicogenic dizziness: a prospective case series clinical study. J Exerc Rehabil. 2016;12(3):216-225. PMC4934967 · PMID 27419118.
  2. Chu ECP, Al Zoubi F, Yang J. Cervicogenic Dizziness Associated With Craniocervical Instability: A Case Report. J Med Cases. 2021;12(11):451-454. PMC8577610 · PMID 34804305.
  3. Teare-Ketter A, LaForme Fiss A, Ebert J. The Utility of Neuromotor Retraining to Augment Manual Therapy and Vestibular Rehabilitation in a Patient with Post-Concussion Syndrome: A Case Report. Int J Sports Phys Ther. 2021;16(1):248-258. PMC7872469 · PMID 33604153.
  4. Marshall CM, Vernon H, Leddy JJ, Baldwin BA. The role of the cervical spine in post-concussion syndrome. Phys Sportsmed. 2015;43(3):274-284. PMID 26138797.
  5. Cheever K, McDevitt J, Phillips J, Kawata K. The Role of Cervical Symptoms in Post-concussion Management: A Systematic Review. Sports Med. 2021;51(9):1875-1891. PMID 33891292.
  6. De Vestel C, Vereeck L, Reid SA, et al. Systematic review and meta-analysis of the therapeutic management of patients with cervicogenic dizziness. J Man Manip Ther. 2022;30(5):273-283. PMID 35383538.
  7. Nissen T, Wynn R. The clinical case report: a review of its merits and limitations. BMC Res Notes. 2014;7:264. PMID 24758689.

How do you apply these recommendations concretely in your practice?

In this chapter: the red flags specific to CGD (5Ds and 3Ns, Finucane 2020), criteria for multidisciplinary referral (ENT, neurology, psychology), validated PROMs (DHI MCID 18, NDI MCID 7.5), the barriers to implementation and the tension between standardisation and personalisation.
Applying research-based recommendations means knowing what to do, when to collaborate and how to measure the impact. 🧑‍⚕️

When and to which other health professionals should you refer?

Identifying the red flags (see the box in chapter 2) is the first non-negotiable step. The international framework Finucane 2020 (JOSPT) stresses that many traditional red flags have poor diagnostic accuracy taken in isolation and must be read in the context of a full examination.¹ Beyond emergencies, the presence of yellow flags (catastrophising, kinesiophobia, anxiety, depression) predicts chronicity. The prevalence of anxiety in vestibular patients reaches 30-47 % depending on the condition (Kim 2024 meta-analysis, n = 764 403).² Referral to a clinical psychologist trained in cognitive behavioural therapy is indicated where HADS-A ≥ 11, PCS > 30, TSK ≥ 37, or PHQ-9 > 10.
🤝 Multidisciplinary referral by clinical profile
Clinical profileReferralRationale
Resistant dizziness + tinnitus / hearing lossENT + audiometryRule out Ménière's, vestibular neuronitis
Associated migraine headacheNeurologistLempert 2022 vestibular migraine criteria
High anxiety + symptoms > 3 monthsPsychologist / psychiatristRisk of PPPD (Staab 2017, ICD-11 AB32.0)
Suspected craniocervical instabilityDynamic imaging + specialistThe Chu 2021 case: rare, but worth knowing
Vascular symptoms (5Ds and 3Ns)Emergency department / neurologistSuspected VBI (2025 SR)
Athlete with persistent post-concussion symptomsSports physician + neuropsychologyMarshall 2015, Cheever 2021
Structured interprofessional collaboration is central. The physiotherapist, often the first point of contact, plays a triage role. Clear communication and defined referral protocols with ENT specialists, neurologists and psychologists optimise the care pathway.

How do you measure outcomes and overcome barriers to implementation?

Systematic use of Patient-Reported Outcome Measures (PROMs) is now a quality standard. 📈 For CGD, three tools are essential:
DHI0-100 · MCID = 18 pts (Jacobson 1990) · severe threshold > 60
NDI0-50 · MCID = 7.5 pts (Carreon 2010; 5.5 without radicular pain, Young 2018)
NRS0-10 · MCID = 2 pts for dizziness and for neck pain
JPSEObjective measure of motor control · threshold < 3°
Recommended practice: assess DHI + NDI + dizziness NRS + neck pain NRS at each key consultation (baseline, 4 weeks, 8 weeks, 12 weeks, 6 months). A patient symptom diary usefully complements these PROMs. The gap between knowledge and practice is documented: the systematic review Scurlock-Evans 2014 identifies three major barriers to implementing EBP in physiotherapy: lack of time, lack of critical appraisal skills, and lack of organisational support.³ Effective strategies: in-practice journal clubs, pre-appraised resources (PEDro, Cochrane), peer mentoring.

Critique and controversy: beyond the guidelines

First, the tension between standardisation and personalisation. Practice guidelines are based on population averages. Every patient is unique. Greenhalgh 2014 (BMJ) warned of an “EBM crisis”: rigid application of protocols can damage the therapeutic alliance, a factor that is nonetheless essential to good outcomes; Ferreira 2013 quantified that effect in chronic low back pain.⁴٬⁵ Second, the focus on PROMs can obscure other aspects of recovery (subjective quality of life, return to valued activities), and data collection must not come at the expense of time spent listening. Third, equity of access to the recommended referrals (psychologist, neurologist, ENT) varies widely between regions. The physiotherapist is often left on the front line managing the complexity, which highlights the structural limits of the health system more than those of individual practice.

Key points, chapter 6

  • 🚩 Systematically look for the red flags (5Ds and 3Ns, neurological deficit) and refer urgently (Finucane 2020).
  • 💛 Screen for the yellow flags (anxiety 30-47 %, catastrophising, kinesiophobia); collaboration with a psychologist is indicated (Kim 2024).
  • 📊 Use validated PROMs : DHI (MCID 18), NDI (MCID 7.5), dizziness and neck pain NRS (MCID 2).
  • 🤝 Refer to a psychologist, neurologist or ENT specialist according to the specific profile.
  • ⚖️ Balance standardisation (the recommendations) against personalisation (the therapeutic alliance, Ferreira 2013).
Bibliography
  1. Finucane LM, Downie A, Mercer C, et al. International Framework for Red Flags for Potential Serious Spinal Pathologies. J Orthop Sports Phys Ther. 2020;50(7):350-372. PMID 32438853 · doi:10.2519/jospt.2020.9971.
  2. Kim SK, Yeo BSY et al. Anxiety and Depression in Adults With Vestibular Disorders: A Systematic Review and Meta-Analysis. Laryngoscope. 2024. doi:10.1002/lary.70055.
  3. Scurlock-Evans L, Upton P, Upton D. Evidence-Based Practice in physiotherapy: a systematic review of barriers, enablers and interventions. Physiotherapy. 2014;100(3):208-219. PMID 24799154.
  4. Greenhalgh T, Howick J, Maskrey N. Evidence based medicine: a movement in crisis? BMJ. 2014;348:g3725. PMID 24927763.
  5. Ferreira PH, Ferreira ML, Maher CG, Refshauge KM, Latimer J, Adams RD. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Phys Ther. 2013;93(4):470-478. PMID 23139428.
  6. Carreon LY, Glassman SD, Campbell MJ, Anderson PA. Neck Disability Index, short form-36 physical component summary, and pain scales for neck and arm pain: the minimum clinically important difference and substantial clinical benefit after cervical spine fusion. Spine J. 2010;10(6):469-474. PMID 20359958.
  7. Young IA, Dunning J, Butts R, Mourad F, Cleland JA. Reliability, construct validity, and responsiveness of the Neck Disability Index and Numeric Pain Rating Scale in patients with mechanical neck pain without upper extremity symptoms. Physiother Theory Pract. 2018. PMID 29856244.

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This article has undergone rigorous bibliographic checking: every reference cited is linked to a verified PubMed PMID or CrossRef DOI. The figures and claims are sourced. The clinical cases cited come from the published literature.

Last revisedMay 2026 MethodA synthesis of meta-analyses + international consensus statements (Bárány Society 2022) Level of evidenceMixed (from level 1a meta-analyses to level 5 case reports, ranked within the article) Conflicts of interestNone declared A question, or spotted an error?WhatsApp button at the bottom right of the screen 💬

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