Cases · Central reweighting · trainee

Whiplash 14 months ago, still off-balance

A 38-year-old teacher 14 months post-whiplash, with persistent visual dependence and avoidance.

Vignette

A 38-year-old primary-school teacher was rear-ended at low speed 14 months ago. She had immediate neck pain and within a week developed a foggy disequilibrium that has not resolved. Her cervical pain has improved with physiotherapy from a baseline 8/10 to a current 3/10, but the dizziness has not tracked the pain. She now describes feeling 'off' most days, much worse in supermarkets and on the school playground, better when sitting in a quiet office. She has stopped driving on motorways. She scores high on the Dizziness Handicap Inventory (62/100). She has had vestibular physiotherapy with another provider for three months without improvement.

Examination and workup

Cervical examination shows mildly reduced rotation (within 80% of normal), modest tenderness over C2/3 facets, cervical torsion test mildly positive (symptoms reproduced but less intense than in acute presentations). JPE 4.7° on right rotation, 4.0° on left — borderline. SPNT difference 0.12 — borderline. Dix-Hallpike, supine roll, vHIT, calorics all normal. SOT shows a visual-preference pattern (abnormal in conditions 3 and 6, normal in conditions 5 and 6 — pattern consistent with visually-induced dizziness, not vestibular loss). Patient describes avoiding situations with patterned floors, scrolling text on her phone, and large open spaces. Mood screen suggests low-grade anxiety.

Question

What is the most appropriate next step in management?

AContinue the cervical manual therapy that has been the mainstay of her treatment so far, and review in 12 weeks
BShift the focus to visual desensitisation and vestibular rehabilitation focused on sensory reweighting back toward proprioception, while maintaining the cervical work as an adjunct
CRefer for cervical spine MRI to look for occult post-traumatic ligamentous injury that may have been missed
DTrial of long-term betahistine 16 mg three times daily
ERefer to neurology for further investigation of the persistent symptoms

Select an option to reveal the answer.

Teaching point

Whiplash patients commonly progress from a Route 1 (proprioceptive) presentation in the first few months to a Route 4 (central reweighting) presentation later. The SOT pattern, the trigger profile (busy visual environments rather than specific neck positions), and the avoidance behaviour are the key signals. When pain has improved but dizziness persists, the mechanism has shifted — and so should the treatment.

References

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
² Kristjansson E, Treleaven J (2009). Sensorimotor function and dizziness in neck pain: implications for assessment and management. Journal of Orthopaedic & Sports Physical Therapy, 39(5):364–377. link
²⁵ Thompson-Harvey A, Hain TC (2019). Symptoms in cervical vertigo. Laryngoscope Investigative Otolaryngology, 4(1):109–115. link
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
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