Cases · Proprioceptive mismatch · foundation

The office worker with a stiff neck and unsteadiness

Eight months of neck pain and intermittent dizziness in a 42-year-old IT consultant.

Vignette

A 42-year-old IT consultant presents with eight months of intermittent dizziness, worse at the end of long working days. She describes a 'foggy unsteadiness' rather than spinning, lasting minutes at a time, and reliably appears when she has been holding her head forward at her monitor. Co-existing posterior neck and upper trapezius stiffness, with one episode of headache per week. No hearing change, no nausea-and-vomiting, no syncope. She has a desk-based job, two children, sleeps badly.

Examination and workup

Examination shows restricted upper cervical rotation (L > R, end-range pain at both), tender right occipitalis insertion and bilateral suboccipital points, and reproducible heaviness on sustained 30° left rotation held for 20 seconds. Cervical torsion test positive — symptoms reproduced with body-on-head rotation while head stays still. Joint position error measured with laser pointer: 6.8° on right rotation, 4.1° on left (normal <4.5°). SPNT difference 0.18 (normal <0.10). Dix-Hallpike and supine roll negative bilaterally. vHIT normal both sides (gain 0.92 R, 0.94 L). Audiogram symmetric. No central oculomotor signs. Neurological examination otherwise normal.

Question

Which is the most appropriate first-line treatment plan?

AUpper-cervical mobilisation, cervical proprioceptive retraining using a laser pointer, and deep cervical flexor strengthening for 6–12 weeks
BVestibular rehabilitation with gaze stabilisation and habituation exercises as the primary intervention
CLong-term soft cervical collar to immobilise the painful segments while symptoms settle
DCinnarizine 15 mg three times daily for 6 weeks, with review thereafter
EMRI cervical spine and MRA neck to characterise the structural pathology

Select an option to reveal the answer.

Teaching point

The textbook Route 1 patient — reproducible cervical findings on examination, abnormal cervical-proprioceptive tests, clean vestibular workup. Treatment is manual therapy plus cervical proprioceptive retraining plus deep cervical flexor work. Recognise the pattern and avoid the four common false routes: habituation as primary intervention, collars, stacked vestibular suppressants, and imaging without indication.

References

¹¹ Reid SA, Rivett DA (2005). Manual therapy treatment of cervicogenic dizziness: a systematic review. Manual Therapy, 10(1):4–13. link
⁴² Lystad RP, Bell G, Bonnevie-Svendsen M, Carter CV (2011). Manual therapy with and without vestibular rehabilitation for cervicogenic dizziness: a systematic review. Chiropractic & Manual Therapies, 19(1):21. link
⁴³ Reid SA, Callister R, Katekar MG, Rivett DA (2014). Effects of cervical spine manual therapy on range of motion, head repositioning, and balance in participants with cervicogenic dizziness: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 95(9):1603–1612. 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
¹ Treleaven J (2008). Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control. Manual Therapy, 13(1):2–11. link
¹⁷ Revel M, Andre-Deshays C, Minguet M (1991). Cervicocephalic kinesthetic sensibility in patients with cervical pain. Archives of Physical Medicine and Rehabilitation, 72(5):288–291. link
³⁴ Caro-Codón J, Pérez-Fernández N (2019). Cervical spine radiographs in patients with vertigo and dizziness. Journal of Vestibular Research, 29(5):255–262. link