When a Concussion Leaves You Spinning

The Science of Vestibular and Cervical Rehabilitation

Dizziness, imbalance, and that persistent feeling of “not quite right” are among the most disabling—and most treatable—consequences of a concussion.

Understanding the Aftermath of a Concussion

A concussion—technically a mild traumatic brain injury (mTBI)—is far more than a temporary headache. The forces involved in even a moderate impact can disrupt multiple interconnected systems: the vestibular apparatus of the inner ear, the proprioceptive pathways of the cervical spine, and the intricate neural circuits that weave them together. For a significant proportion of patients, these disruptions persist long after the initial injury.

If you are a professional in a demanding environment—presenting to clients, navigating busy streets, staring at two screens simultaneously—the lingering effects of a concussion are not merely inconvenient. They are professionally and personally costly. The encouraging reality: these symptoms respond exceptionally well to targeted, evidence-based physical therapy when the right systems are identified and treated.

“In most cases symptoms will resolve in the initial few days following concussion, after which time a gradual return to sport and school strategy is recommended. If symptoms persist for longer than 7–10 days, a multifaceted interdisciplinary assessment is recommended.”

Schneider et al., J Orthop Sports Phys Ther, 2019

Two Distinct—but Often Overlapping—Problems

Post-concussion dizziness and imbalance typically arise from one or both of the following sources. Distinguishing between them is the foundation of effective treatment.

• Vestibular System Dysfunction
  • The vestibular system, housed in the inner ear, is your brain’s primary source of information about head position and movement in space.
  • A concussion can disturb this system by:
    • displacement of the calcium carbonate crystals (otoconia) that line the inner ear canals, causing benign paroxysmal positional vertigo (BPPV)
    • disruption of the fluid dynamics within the semicircular canals
    • injury to the central pathways that process vestibular signals
  • The result is a mismatch between what your eyes see, what your inner ear senses, and what your body feels:
    • vertigo
    • unsteadiness
    • nausea
    • difficulty tracking text on a screen

• Cervicogenic Dizziness
  • Less well-known
  • Cervicogenic dizziness (CD) originates in the neck rather than the inner ear.
    • The cervical spine is densely populated with
      • proprioceptive receptors (joint position)
      • mechanoreceptors in the joints, muscles
      • fascia of the upper cervical segments
    • These all continuously relay information about head position to the brainstem.
  • When a concussion involves a whiplash mechanism or a direct blow that disturbs upper cervical mobility, these signals become distorted.
  • A recent systematic review found that cervicogenic dizziness appears in 35–40% of patients with neck pain, a prevalence higher than many clinicians appreciate (Casado-Sánchez et al., 2024).

Critically, these two conditions frequently co-exist following concussion. Research published in the Journal of Orthopaedic & Sports Physical Therapy confirmed that a neck injury was present in approximately half of post-concussion patients assessed, and that many showed signs of concurrent vestibulo-ocular dysfunction alongside cervicogenic symptoms—underscoring the importance of evaluating both systems together.

Vestibular Rehabilitation Therapy: The Evidence

Vestibular Rehabilitation Therapy (VRT) is an exercise-based program designed to promote vestibular habituation, adaptation, and substitution. Its goals are to enhance gaze stability, restore postural control, and return patients to their full functional capacity.

Why rest alone is not the answer. The long-standing advice to simply “rest in a dark room” is not supported by current evidence. Multiple systematic reviews now show that early, targeted intervention—not prolonged rest—leads to faster resolution of symptoms and quicker return to work and activity.

A 2023 systematic review covering research from 2011 to 2023 concluded that vestibular rehabilitation therapy shows meaningful promise in improving dizziness and imbalance symptoms in those who have suffered sport-related concussions (Pardue, Michaels & Felipe, 2023). A separate systematic review of randomized controlled trials found that VRT in the acute phase appears effective in reducing time to return-to-sport, with a meta-analysis demonstrating positive short-term effects on dizziness (PMC, 2023). Importantly, early intervention appears to matter: athletes who received vestibular rehabilitation early in their recovery demonstrated superior resolution of balance deficits compared to those who began therapy later (Babula et al., IJSPT, 2023).

What VRT Looks Like in Practice

An individualized VRT program is not a fixed protocol—it is calibrated to each patient’s presentation and response. Schneider and colleagues (2019) emphasize that an individualized, patient-centered approach is essential, given that intrinsic factors specific to each person significantly influence both concussion risk and recovery trajectory. At our clinic, your program will be designed around your specific symptom profile, occupational demands, and functional goals.

Manual Therapy for the Cervical Spine: An Often-Missing Piece

When cervicogenic dizziness is part of the clinical picture—and in post-concussion patients, it frequently is—vestibular rehabilitation alone may not be sufficient. Manual therapy directed at the upper cervical spine addresses the proprioceptive dysfunction that lies at the root of cervicogenic dizziness.

A 2024 systematic review (Casado-Sánchez et al.) analyzed eight high-quality randomized controlled trials and found consistent, statistically significant improvements in dizziness intensity and cervical range of motion in patients who received manual therapy for cervicogenic dizziness. The techniques with the strongest evidence include Mulligan’s Sustained Natural Apophyseal Glides (SNAGs), which demonstrated particularly robust short-term gains in cervical range of motion; Maitland passive joint mobilizations, which in combination with exercise, showed sustained benefits at 12-month follow-up; and high-speed, low-amplitude thrust techniques directed at the C0–C3 segments, which produced significant reductions in dizziness and pain at 48 hours and one month post-treatment.

“Manual therapy may provide added value to the benefits of exercise in reducing cervicogenic headache and associated neck pain and dysfunction… restoring cervical ROM may well be one factor affecting outcomes.” PMC — Sequencing and Integration of Cervical Manual Therapy and Vestibulo-oculomotor Therapy, 2021

Treating the cervical spine in isolation, or vestibular rehabilitation in isolation, when both systems are impaired, is unlikely to yield optimal results. The most current clinical practice guidelines from the American Physical Therapy Association explicitly include cervical musculoskeletal treatment alongside vestibulo-oculomotor and autonomic interventions as part of best practice for post-concussion physical therapy care.

The Bio-Psycho-Social Dimension

Chronic dizziness and imbalance do not exist in a vacuum. Anxiety, depression, and kinesiophobia (fear of movement) are well-documented amplifiers of vestibular and cervicogenic symptoms, creating a feedback loop that impedes recovery. A notable study by Micarelli and colleagues found statistically significant improvements in anxiety, depression, and kinesiophobia scores alongside physical outcomes following manual therapy for cervicogenic dizziness—reinforcing that effective treatment must address psychological factors as part of a comprehensive approach.

For professionals returning to high-stakes cognitive work, this matters enormously. Confidence in movement, reduced fear of symptom provocation, and normalized activity are outcomes that are just as important as reduced dizziness scores on a standardized scale.

Our Approach at Downtown Manhattan PT

Our evaluation begins by determining which systems are contributing to your symptoms—vestibular, cervical, visual, or a combination. This guides a genuinely individualized treatment plan rather than a one-size-fits-all protocol. We integrate vestibular rehabilitation with manual therapy of the cervical spine when indicated, alongside exertional tolerance work and coordination with your other treating providers.

References

1. Alsalaheen BA, et al. Vestibular rehabilitation for dizziness and balance disorders after concussion. J Neurol Phys Ther. 2010;34(2):87–93.
2. Schneider KJ, Emery CA, Black A, Yeates KO, Debert CT, Lun V, Meeuwisse WH. Adapting the Dynamic, Recursive Model of Sport Injury to Concussion: An Individualized Approach to Concussion Prevention, Detection, Assessment, and Treatment. J Orthop Sports Phys Ther. 2019 Oct 14. doi:10.2519/jospt.2019.8926.
3. Casado-Sánchez A, Sancio-Fernández D, Seijas-Otero D, et al. Effectiveness of Manual Therapy in Dizziness intensity and cervical range of motion in patients with Cervicogenic Dizziness: a systematic review. European Journal of Human Movement. 2024.
4. Pardue C, Michaels M, Felipe L. Effectiveness of vestibular rehabilitation therapy (VRT) after persistent dizziness following sport-related concussion: a systematic review of the literature. J Otolaryngol ENT Res. 2023;15(2):76–79.
5. Babula G, Warunek E, Cure K, Nikolski G, Fritz H, Barker S. Vestibular Rehabilitation as an Early Intervention in Athletes Who are Post-concussion: A Systematic Review. Int J Sports Phys Ther. 2023;18(3):577–586. doi:10.26603/001c.75369.
6. Effectiveness of Vestibular Rehabilitation after Concussion: A Systematic Review of Randomised Controlled Trials. PMC / MDPI. 2023. doi:10.3390/jcm12010062.
7. Reid SA, et al. Efficacy of manual therapy treatments for people with cervicogenic dizziness and pain: protocol of a randomised controlled trial. BMC Musculoskelet Disord. 2012;13:201. doi:10.1186/1471-2474-13-201.
8. Sequencing and Integration of Cervical Manual Therapy and Vestibulo-oculomotor Therapy for Concussion Symptoms: Retrospective Analysis. PMC. 2021.
9. Reid SA, et al. Can the neck contribute to persistent symptoms post concussion? J Orthop Sports Phys Ther. 2019. doi:10.2519/jospt.2019.8547.