Cases · PPPD (trap) · clinician

The chronic dizzy patient who fails manual therapy

A 49-year-old with 9 months of daily unsteadiness — the wrong-route case.

Vignette

A 49-year-old engineer was diagnosed with cervicogenic dizziness 9 months ago after an acute BPPV episode that resolved with Epley. He has had structured manual therapy and cervical proprioceptive retraining for six months without progress. He describes daily unsteadiness from waking through to mid-evening, worse when he is upright and walking, worse in the open-plan office at work, much worse on the escalator and in shopping centres. He sleeps poorly and worries about falling. He has stopped jogging. His Dizziness Handicap Inventory score is 58/100 — unchanged across two reviews.

Examination and workup

Cervical examination is now near-normal — minor restricted upper cervical rotation, negative cervical torsion test, normal JPE, normal SPNT. vHIT, VNG, calorics, audiometry all normal. Dix-Hallpike and supine roll normal. SOT shows the visual-preference pattern (abnormal conditions 3 and 6). Mood screen consistent with low-grade anxiety. No central oculomotor signs.

Question

Which is the most appropriate primary management strategy now?

AAdd vestibular suppressant therapy with cinnarizine to the existing programme
BContinue the manual therapy programme with greater intensity, given the chronicity
CReframe as PPPD per Staab criteria — vestibular rehabilitation with sensory reweighting and visual desensitisation, with cognitive-behavioural elements for the avoidance, and consider SSRI/SNRI trial
DRefer to neurosurgery for cervical surgical assessment given the prolonged failure of conservative measures
ERepeat the entire vestibular workup to exclude a missed peripheral disorder

Select an option to reveal the answer.

Teaching point

The cervicogenic patient who does not improve at 6–12 weeks on a correctly-identified route is rarely a refractory cervicogenic patient — they are usually a different diagnosis in disguise, or in this case a *correct-original-diagnosis-with-shifted-mechanism*. When manual therapy and proprioceptive retraining have failed in a patient whose cervical examination has normalised, reconsider the mechanism rather than intensifying the treatment. PPPD is a frequent endpoint after a discrete vestibular event and is treatable on its own terms. The Module 8 outcome-assessment phase — re-evaluate when progress fails — is precisely for this scenario.

References

³⁸ Staab JP, Eckhardt-Henn A, Horii A, Jacob R, Strupp M, Brandt T, Bronstein A (2017). Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society. Journal of Vestibular Research, 27(4):191–208. link
³ Treleaven J (2017). Dizziness, unsteadiness, visual disturbances, and sensorimotor control in traumatic neck pain. Journal of Orthopaedic & Sports Physical Therapy, 47(7):492–502. link
⁴⁴ Sremakaew M, Jull G, Treleaven J, Uthaikhup S (2023). Effectiveness of adding rehabilitation of cervical related sensorimotor control to manual therapy and exercise for neck pain: A randomized controlled trial. Musculoskeletal Science and Practice, 63:102690. link