Continuing Education Bits for PTs & PTAs

INTRODUCTION, by Marilyn Pink, PT, Ph.D. — And so, we arrive at the 4th and final post in this case study by Dr. Landel. We hope that you’ve acquired new insights, and we very much appreciate your comments. They provide additional dimensions to a discussion that is, by all measures, very rich. So, don’t be shy and participate once more, as Rob closes out with icing on the cake!

Rob Landel

Guest blogger Rob Landel, PT, DPT, OCS, CSCS, FAPTA

What would be your initial treatment intervention?

By guest blogger, Dr. Robert Landel

  • The cervical spine has some significant impairments, understandable given her recent MVA and complaints of neck pain.
  • All PE findings suggest a normal central nervous system.
  • Oculomotor exam suggests no central vestibular pathology.
  • Head thrust suggests no peripheral vestibular hypofunction.
  • Report of instability (without falls) suggests a balance issue. Balance testing reveals a normal Rhomberg, but this is not a sensitive test. Sharpened Rhomberg, mCTSIB and SLS testing suggest further that there are balance issues. Of interest is the difficulty with SLS while the head is rotated right.
  • Flexibility tests are non-contributory but you might consider addressing these.
  • Positional testing is positive and suggests a right posterior canal canalithiasis BPPV. Horizontal canals appear normal

Thus, my approach would be to address the BPPV first using a canalith repositioning maneuver, or CRM. This is highly likely to resolve the BPPV within one treatment. My preference is to do one CRM, and send the patient home without doing other treatments, with a return visit in a week or sooner. I do not give post-CRM precautions.

As to prognosis…

As I noted above, very good for the BPPV. (Helminski et al., 2010) However, patients can have continued complaints of dizziness despite resolution of their BPPV (as defined by no nystagmus or vertigo during the Dix-Hallpike maneuver). (Seok et al., 2008)

In this patient’s case she complained of continuing dizziness despite a successful CRM. Since there were no central vestibular signs, and once the BPPV was cleared there were no clinical signs of peripheral vestibular pathologies, the possibility of cervicogenic dizziness comes to the forefront. This is particularly true when the dizziness is accompanied by neck pain. (Wrisley et al., 2000). As noted above, the difficulty with SLS while the head is rotated right is significant; this suggests that the cervical spine is playing a role in her postural instability. Further testing is warranted at this point, and in particular, testing for cervical sensorimotor impairments. An excellent article to review this is by Kristjansson and Treleaven (Kristjansson & Treleaven, 2009) and I highly recommend you read it if you treat patients with neck pain. To summarize, sensorimotor impairments can cause a variety of symptoms, and clinical tests are available to help determine the problem and potential solutions. The table below is a summary:

Each component needs to be assessed and treated. Here are some suggestions:


  • Use a laser on the head to provide feedback while the patient practices returning the head to a starting position, eyes open (knowledge of performance) and eyes closed (knowledge of results).
  • neck flexor strengthening improves head JPE. (Jull et al., 2007)

Neck Movement Control:

  • Practice tracing patterns using the laser on the head.
  • Strengthen the deep neck flexors and the cervical and capital extensors.

Postural stability:

  • Neck extensor endurance is also very important for postural control; subjects whose neck extensor muscles fatigue have been shown to have increased postural sway. Just as importantly, the authors were able to improve postural sway by training the neck extensors. (Stapley et al., 2006)
  • This patient exhibits some LE impairments that will adversely affect balance, namely LE weakness, and these will need to be addressed.

Oculomotor control: practice smooth pursuit with the head in neutral and with the body turned underneath a stable head. Do the same with saccades.

Let’s not forget the other cervical spine impairments we found earlier, mainly, reduced ROM. For this, use your joint and soft tissue mobilization, whichever particular flavor works well for you, and follow your manual therapy with appropriate exercises.

I hope you found this patient case interesting, and I welcome comments and suggestions. Perhaps I’ll see you at a future course or conference!

Best regards,



Helminski JO, Zee DS, Janssen I, Hain TC. Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: A systematic review. Phys Ther 2010: 90(5): 663-678.
Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B. Retraining cervical joint position sense: The effect of two exercise regimes. J Orthop Res 2007: 25(3): 404-412.
Kristjansson E, Treleaven J. Sensorimotor function and dizziness in neck pain: Implications for assessment and management. J Orthop Sports Phys Ther 2009: 39(5): 364-377.
Seok JI, Lee HM, Yoo JH, Lee DK. Residual dizziness after successful repositioning treatment in patients with benign paroxysmal positional vertigo. J Clin Neurol 2008: 4(3): 107-110.
Stapley PJ, Beretta MV, Dalla Toffola E, Schieppati M. Neck muscle fatigue and postural control in patients with whiplash injury. Clinical Neurophysiology 2006: 117(3): 610-622.
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.


Comments on: "My Own Approach To This Case" (5)

  1. I hope you will engage an Occupational Therapist who would address how she is adapting what she needs to do so she feels safe, is safe, and stays active. I would encourage an outpatient home visit by an OT, or at least address these issues in the clinic: loading dishwasher, feeding cat, raking leaves, showering with eyes closed, walking in dark anywhere? etc.

  2. If the dizziness is cervicogenic, why not fix the issue with the neck? HVLAT of C0-C1 or C1-C2 will likely remedy the issue. Assessing the mobility of these levels will demonstrate which is the culprit, and moderate pressure on the responsible segment will likely increase symptoms. Then send them home with movement activities and deep neck flexor strength activities. It generally will take 2-4 visits for symptoms to completely resolve, but they will leave with significant improvmement after this treatment. There is very little research on HVLAT and dizziness to back it up but I see it several times a week in my practice.

  3. Thanks, Dr. Landel, I enjoyed this following and participating in this discussion. I think it very clearly illustrated the necessity of an organized thought process and that as PTs move more into the direct access area with ever more complicated patients, we have to continually challenge ourselves to maintain high levels of knowledge and skill. We can’t just be neuro or ortho PTs, but realize all of our evaluation skills and treatment tools are needed to provide effective care for the patients we are privileged to treat. There isn’t a tool we learn in PT school that we ever get to put back in the tool box.

    • Marilyn M. Pink PT, Ph.D. CEO, EDUCATA said:

      Jennifer: Thank you very much for your feedback to Dr. Landel. Rarely do folks take the time to share appreciation, and I thank you for that. (Sometimes we work in a void and wonder if we are really helping therapists learn and be the quality we all want to be.) I’ve known Rob for about 4 years now. I can’t speak highly enough of him – and I’m so happy that you can see his quality too. So, Rob: I share Jennifer’s ‘Thanks’. You are the best!

      • Pierluigi said:

        Thank you very much for the case. It stimulated me to revise this topic. I liked the way Dr Landel unravelled the case.

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