Cervicogenic dizziness is a controversial diagnosis caused by dysfunction in the upper cervical spine that results in imbalance or disequilibrium. It is identified through a 5-step process including characteristics of imbalance-type dizziness, neck pain or stiffness exacerbating dizziness, and physical exam findings. Sustained natural apophyseal glides are an effective manual therapy treatment, shown to decrease dizziness and pain more than mobilizations or placebo. Multi-modal treatment including balance exercises is also recommended. Long-term follow up shows treatment effects are maintained for up to 12 months.

1. Cervicogenic Dizziness:
identification and treatment
Sue Reid (PhD, MMedScPhty, GradDipManipTher,
BAppSC(Phty), BPharm)

2. Dizziness
• Dizziness is a common problem: 200 mill visits annually (Newman-
Toker 2012)
• Many types of dizziness and causes
• Diagnosis challenging: 50% misdiagnosed (Newman-Toker 2012)
• Cost to diagnose: $2,500 per patient

3. Traditionally divided according to
quality-of-symptoms (Drachman & Hart 1972)
Symptom Possible cause
Imbalance, unsteadiness Cervicogenic dizziness, musculoskeletal
disorders, vestibular problems
Near syncope (faint), light-headedness Cardiovascular causes
Confusion, anxiety Psychogenic dizziness
Vertigo Peripheral vestibular,
Central nervous system

4. Vertigo
• A sensation of movement
• Rotatory or spinning
• Nausea/ vomiting
• The most common type of dizziness (Hain 2004)
• Caused by central nervous system or
peripheral vestibular disorders

5. Descriptions of dizziness
• Descriptions of dizziness: vague, unclear,
inconsistent and unreliable
• 62% (n=872) selected more than one type of
dizziness (Newman-Toker et al 2007)
• 52% picked a different response on retest 6
minutes later (Newman-Toker et al 2007)
• More reliable: behaviour of dizziness e.g.
duration, triggers and associated symptoms

6. Cervicogenic dizziness
Dizziness
described as
imbalance or
disequilibrium
Provoked by head
movements or
positions
Associated with
neck pain or
stiffness

7. Vestibular
Nuclei
Vestibular
system
Visual
system
Proprioceptors
of the cervical
joints and
muscles
(Cronin 1997, Furman & Whitney 2000)
Inputs to the vestibular nuclei
that maintain balance

8. Cause of cervicogenic dizziness?
Dysfunction of
upper cervical joint
receptors or deep
cervical muscles
(Brandt 1991, Reid et al
2008, Wrisley et al 2000)
Result of a
perturbation in
the information
from sensory
afferents in the
cervical spine
(Brandt & Bronstein 2001)

9. Identification of cervicogenic
dizziness
• No diagnostic test, hence controversial diagnosis
• Five step process developed
• Shown to be successful as previous studies using
this identified people with CD and then they were
successfully treated (Reid et al 2008, 2014, 2015)
• Can be used clinically to identify people and offer
appropriate treatment

10. Diagnostic process for cervicogenic
dizziness
1) Type of dizziness
2) Eliminate other causes for dizziness or
unsteadiness
3) Neck pain and/or stiffness
4) Provocation by cervical movements
5) Physical tests: ROM, cervical signs on
palpation, balance, Dix-Hallpike test

11. 1. Dizziness characteristics
• Must be consistent with cervicogenic
dizziness
• UNSTEADINESS imbalance, disequilibrium
• Exclude other types of dizziness – vertigo,
presyncope, anxiety
• Ask about dizziness behaviour: onset,
severity, frequency, duration

12. 2. Elimination of other causes of
dizziness or unsteadiness
• Ask about stroke, spinal cord pathology,
cerebellar ataxia, Parkinson’s disease

13. 3. Presence of neck pain or
stiffness
• Neck pain, discomfort, neck stiffness, occipital pain
and/or headache (Malmstrom et al 2009)
• Less common: TMJ pain (Malmstom et al 2009),
radiculopathy (Schenk et al 2006; Wrisley et al 2000,)
ear fullness, blurred vision, sweating, tinnitus,
problems with swallowing,
• History of pain behaviour: onset, duration, frequency,
aggravating and easing factors

14. 4. Provocation of dizziness
by neck movements
• The unsteadiness or poor balance
must be exacerbated by cervical
movements or positions
• Usually extension, or rotation (Mulligan
1999, Reid et al 2008)

15. 5. Physical examination
• Cervical ROM
• Palpation of soft tissues (upper cervical
spine)
• Passive accessory intervertebral
movements: PA and unilateral PA pressures
(occiput to C3)
• Balance
• Smooth pursuit neck torsion test
• Dix-Hallpike manoeuvre to identify BPPV

16. Identification of cervicogenic dizziness
Patients treated with manual therapy had
decreased dizziness and pain after 2-4
treatments with Mulligan SNAGs (Reid et al
2008, 2014, 2015 )
Prompt favourable response to manual
therapy treatment helps identify this
condition

17. Differential diagnosis of cervicogenic
dizziness
• Benign Paroxysmal Positional Vertigo (BPPV)
• VBI (including VA dissection)
• Migraine
• Cardiovascular dizziness

18. Benign paroxysmal positional vertigo
(BPPV)
• Brief, intense, severe rotational vertigo
• The most common causes of vertigo (20-30%)
• Precipitated by changes in head position, rolling
• Usually resolves spontaneously (weeks /mths)
(Brandt & Daroff 1980)

20. BPPV
• Debris from utricle (otoconia: crystals
of Ca Carb) goes into canal
• Usually posterior semicircular canal
(Parnes et al. 2003)

21. Dix-Hallpike manoeuvre
Head turned 45 degrees
to the right
(Bronstein 2003)
Patient taken quickly
into supine head-hanging

22. BPPV (canalithiasis)
Nystagmus
Rotational/torsional
High frequency
Up-beating
Latent (2-15 secs)
Dissipates in <60 sec
Fatigues
Reverses on sitting

23. Treatment of BPPV
Particle re-positioning manoeuvres
Parnes, L. S. et al. (2003). CMAJ,169:681-693
Aim to float the particles into
the vestibule (if canalithliasis)
•Epley manoeuvre:
-Immediate relief in 50-80% of cases (Hain
2004).
-70-90%response 1-3 sessions
•Semont’s manoeuvre
•Brandt Daroff exs: 98% response in 3-14
days

24. Manual therapy treatment of cervicogenic dizziness
Useful treatments;
• Maitland Passive Joint Mobilisations
• Mulligan Sustained Natural Apophyseal Glides
(SNAGs)
• Exercises

25. Sustained natural apophyseal glides (SNAGs) are an
effective treatment for cervicogenic dizziness
Susan A. Reid, Darren A. Rivett, Michael G.
Katekar, Robin Callister Manual Therapy 13
(2008) 357–366
STUDY 1
• RCT compared Mulligan
SNAGs to placebo
• Showed decreased
dizziness, pain, disability
with 4 treatments of SNAGs.
• Effect maintained 12 weeks
• Limitations: no longer term
follow-up, no home
treatment

26. Dizziness• STUDY 2 RCT (2014, 2015)
• SNAGs plus self-SNAGs
• Maitland passive joint
mobilizations (MM) plus
range of motion exercises
• Placebo
• 12 month follow-up
• For dizziness intensity,
frequency and the DHI
SNAG and MM groups better
than placebo
Intensity
DHI
Frequency

27. Extension
• Ext: Significant increase post treatment in the SNAG group but not MM or
placebo. Effect maintained for 12 mths
• SNAG group was better than MM post treatment and at 12 wks.
• For ext and flex SNAG was better than placebo at all time points, while MM was
not better at any time.
STUDY 2 Results ROM

28. SNAG treatment
(Mulligan 1999)
Used physiological movement or
position causing dizziness
Extension (most common)
flexion:
• Anterior glide to C2 spinous process
• Patient extends
• Overpressure added by patient at
end of range
• Repeated six times
• Treatment is symptom-free
Self-SNAG

29. Self- SNAG for extension
Home treatment of self-SNAG into
ipsilateral rotation (x6) once a day

30. SNAG for rotation
SNAG
• Anterior glide to ipsilateral
C1 transverse process
• (If no relief, glide
contralateral process)
• Patient performs rotation
• Overpressure added by
patient at end of range
• Repeated six times
• Treatment is symptom-free

31. Self- SNAG for rotation
Home treatment of self-SNAG into ipsilateral rotation (x6) once a
day

32. Maitland passive joint mobilisations (MM)
Central PA pressure Unilateral PA pressure

33. Maitland passive joint mobilisations
• Used to treat cervical pain and decreased
ROM (Miller 2010)
• Mainstream physiotherapy practice
• Moderate evidence for positive effect on pain,
function and patient satisfaction at
intermediate-term follow-up (Gross et al, 2010)

34. Multi-modal treatment of cervicogenic dizziness
Treat sensorimotor impairments:
• i) Balance eg tandem balance (eyes
open and closed)
• ii) Occulo-motor impairments eg eye
follow, gaze stability exercises, eye and
head co-ordination exercises.
• iii) Cervical joint position error

35. Patient: 76 year old kayaker
•World long distance kayak record;
50km 3/wk
•Turn to right fell out of kayak
•30 years stiff, painful neck
•Post treatment “fantastic” only
occasional dizziness, returned to
sport TK1 Mr N results
0
10
20
30
40
50
60
70
80
90
1 2 3 4
TimelineScores
Dizziness
DHI
Pain

36. In conclusion
• Be informed about the signs and symptoms of these conditions
to identify the cause of the dizziness
• Make a risk assessment prior to manual therapy treatment
• If concerned use gentle pain free treatment techniques

37. References
• Reid SA & Rivett DA. (2005) Manual therapy treatment of cervicogenic dizziness: a
systematic review. Manual Therapy, 10:4-13.
• Reid SA, Rivett DA, Katekar MG & Callister R. (2008) Sustained natural apophyseal glides
(SNAGs) are an effective treatment for cervicogenic dizziness. Manual Therapy, 13:357–366.
• Reid SA, Rivett DA, Katekar MG & Callister R. (2012) Efficacy of manual therapy treatments
for people with cervicogenic dizziness and pain: protocol of a randomised controlled trial.
BMC Musculoskeletal Disorders, 13:201-208.
• Reid SA, Rivett DA, Katekar M & Callister R. (2014) Comparison of Mulligan Sustained Natural
Apophyseal Glides and Maitland Mobilizations for Treatment of Cervicogenic Dizziness: a
Randomized Controlled Trial. Physical Therapy, 94:466-476.
• Reid SA, Rivett DA, Katekar M & Callister R. (2014) The Effects of Cervical Spine Manual
Therapy on Cervical Range of Motion, Head Repositioning and Balance in Participants with
Cervicogenic Dizziness: A Randomized Controlled Trial. Archives of Physical Medicine and
Rehabilitation, 95:1603-12.
• Reid SA, Callister R, Snodgrass SG, Katekar MG & Rivett RA. (2015) Manual therapy
treatment of cervicogenic dizziness: long-term outcomes of a randomised controlled trial.
Manual Therapy, 20:148-156.

38. Acknowledgements
• Australian Catholic University (ACU)
• The University of Newcastle (UoN)
• Prof Darren Rivett (UoN)
• Lucy Thomas (UoN)
• Prof Robin Callister (UoN)
• Dr Michael Katekar, Neurologist Newcastle
• Mulligan Concept Teachers Association Research Grant