Vestibular PT can Aggravate Upper Cervical Dizziness. Sometimes, patients present to vestibular physical therapy with co-occurring upper cervical dizziness.

These patients require special attention since vestibular PT may cause the dizziness to become worse. The first spinal bone below the skull is C1, or the atlas bone. The bone right below is C2, or the axis bone. If the C1 or C2 bones are out of alignment, you may have upper cervical dizziness.

The concepts I explain in this blog are part of The Bell Method® that I have developed over time and trademarked. These concepts are not necessarily widely discussed, accepted, or currently established in traditional health care.

BPPV Treatment

The Epley maneuvers used in vestibular rehab sometimes exacerbate upper cervical dizziness in patients with both BPPV and cervical vertigo. Due to the head hanging down into extension with rotation during the Epley and moving from position one to position two, the pre-existing neck issue can get aggravated.

People with neck pain may experience discomfort in positions one, two, and three of the Epley maneuver. In this blog, I discuss modifications to the Epley maneuver that may help patients with limited neck rotation.

When people feel less vertigo but more lightheaded after many Epleys in vestibular PT, that may be a sign that BPPV is cleared or milder at this point but upper cervical dizziness may still be present or become worse.

At the same time as I make those modifications, I also refer the patient to an upper cervical specialty provider to get their neck treated. My approach is to clear any BPPV concurrently while the patient receives upper cervical care.

I encourage the patient to get their upper cervical adjustment within a day of each BPPV treatment to minimize any potential flare-up, if possible.

Hopefully they can sequence their care to get their upper cervical adjustment either later on the same day or the next day right after each BPPV treatment. That treatment sequence can minimize neck symptom exacerbation after BPPV treatment.

VOR Exercises

People with upper cervical dizziness will likely feel worse with VOR training, due to the quick head shaking involved. The blood supply that passes through the neck to the brain can get restricted if the cervical bones are out of alignment.

This occurs when the C1 or C2 bones are twisted or moved off-center, then the blood vessel can get pinched a bit like a garden hose. If the head is shaking or nodding repeatedly and quickly, dizziness from the neck can be aggravated.

Over time, repetitive stress by fast motion of neck joints that are not lined up properly can potentially cause damage to the neck anatomy.

When patients have upper cervical dizziness, I typically hold off on initiating traditional VOR training until the neck is pain-free.

Each case has to be considered individually to determine if and when it is safe to initiate VOR training, if the patient has neck pain or limited motion. All medical care has potential benefits and potential risks, so these have to be weighed out in every case.

I choose to practice with caution in these situations and use “do not harm” as the guiding principle.

I have treated a number of patients who stated that their neck was harmed by aggressive VOR training with another health care provider that they saw before consulting me.

A few of those patients (that I determined had upper cervical dizziness during my exam) even report that they fainted or passed out right after intense VOR training sessions. In those cases, I referred those patients to an upper cervical care provider and did not do any further VOR training.

If the patient has chronic or recurrent upper cervical issues and they absolutely need VOR training without delay, then I may suggest that they get their neck adjusted within a day before each vestibular physical therapy session.

This sequencing can ensure that the VOR training will have the best chance of occurring while the neck is in proper alignment. That treatment sequence can minimize any neck symptom exacerbation during vestibular physical therapy for VOR training.

You may have noticed that this treatment sequencing strategy between upper cervical care and vestibular rehab for VOR training is the opposite of the sequencing strategy that I suggest during vestibular rehab for BPPV treatment.

For more Barriers to Recovery with Vestibular Rehab, click here and here.


This blog is provided for informational purposes only. The content and any comments by Dr. Kim Bell, DPT are not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. The details of any case mentioned in this post represent a typical patient that Dr. Bell might see and do not describe the circumstances of a specific individual.

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