Clinical Tests For Dizziness

Understanding the correct clinical tests for dizziness is fundamentally important since dizziness can be equally debilitating and frustrating for patients and practitioners. For those suffering from it, it impacts activities of daily living, work, relationships, energy levels, ability to function as well as to recover. It is difficult for practitioners since there are many underlying causes which clinically all present very similarly, yet often require completely different treatment approaches for lasting symptomatic improvement.

Without knowing exactly which kind of dizziness a patient presents with, results can vary significantly, and treatment success is not guaranteed (with a high risk of actually making the patient worse).

Having the right skills and toolset however can turn this challenging clinical entity into an area of competence and confidence which is equally appreciated and rewarded by patients and colleagues who seek advice or refer patients for treatment.

Understanding the variety of causes for dizziness is one of the prerequisites. There are of course inner ear disorders (Meniere’s disease, BPPV), but also neurological conditions such as stroke or tumours. Low blood pressure / hypotension, anaemia, certain medications, alcohol or drug use, anxiety or panic disorders, electrolyte imbalances, cardiac arrhythmias and severe migraines.

Some of these can be differentiated using vestibular function tests, imaging such as CT and MRI, neurological examinations, cardiovascular assessment, and blood tests.

One of the other interesting causes, which is quite common, and yet very commonly misdiagnosed, is cervicogenic dizziness. It’s believed to be caused by disruption of the normal cervical proprioceptive afferent input due to cervical dysfunction (as found in mechanical, degenerative, or inflammatory disorders).

In history taking, a temporal relationship between neck pain or stiffness and the reported dizziness reproduced in the physical examination of the cervical spine needs to be found (where the aggravating behaviour of dizziness in patients was episodic in nature, and associated with neck movement and body-position changes).

As a result of aberrant proprioceptive signals, patients with CGD have dizziness (due to central mismatch with the visual and vestibular systems), postural imbalance (due to abnormal cervico-collic and vestibulo-collic reflex activity), and are more visually dependent (due to increased reliance on visual information).

It is characterised by disturbed:

  • proprioception (head-neck awareness)
  • neck movement control
  • neck range of motion
  • oculomotor function
  • balance
  • postural stability
  • coordination of head, spine and limbs

There are no definitive clinical or laboratory tests for CGD and therefore CGD is a diagnosis of exclusion. It can be difficult for healthcare professionals to differentiate CGD from other vestibular, medical and vascular disorders that cause dizziness. It requires a high level of skill and a thorough understanding of the proper tests and measures to accurately rule in or rule out competing diagnoses.

Once the other most plausible causes are ruled out, tests that are specific for cervicogenic dizziness facilitate honing in on the correct diagnosis. One of the most reliable and accessible methods is the Cervical Neck Torsion Test.


To perform the cervical neck torsion test, the patient begins seated on a swivel chair and turns their trunk maximally (up to) 90° to either the right or left, holding for 30 seconds, then returns their trunk to centre. The patient then repeats the same process in the opposite direction. Each position, including the centre positions, is maintained for 30 seconds. Throughout the test, the head is stabilised by the clinician and therefore motionless. The clinician also must continuously observe for nystagmus/abnormal eye-movements and symptoms.


Treleaven et al. Normative Responses to Clinical Tests for Cervicogenic Dizziness: Clinical Cervical Torsion Test and Head-Neck Differentiation Test. Phys Ther. 2020 Jan 23;100(1):192-200


It is wise to not rely on the results of one test only. The next most reliable and accessible test is the Head-Neck Differentiation Test.


It is similar to the cervical neck torsion test, albeit performed using fast movement oscillations rather than sustained positions. 

Clinical cervical torsion test procedures include 3 components.

Firstly (a), the En bloc component (where head and trunk are rotated together).

Secondly (b), the Torsion component (where the torso is rotated while the head remains still).

Thirdly (c), the Rotation component (where the torso remains still, and the head rotates independently). Trunk, head, or both need to be moved at least 45◦–90◦ degrees to left and right. 

In contrast to the cervical neck torsion test where the patient is held for approximately 30 seconds in each position, in this test the movements are executed relatively rapidly in succession during each component of the test.

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Treleaven et al. Normative Responses to Clinical Tests for Cervicogenic Dizziness: Clinical Cervical Torsion Test and Head-Neck Differentiation Test. Phys Ther. 2020 Jan 23;100(1):192-200


To further determine a specific section or segment that is involved, the Cervical Flexion Rotation Test is recommended.


Cervical Flexion Rotation Test

It is an objective method of determining upper cervical joint (C0-2) dysfunction. To perform the test, the cervical spine is fully flexed in an attempt to isolate movement to C1-C2, which has a unique ability to rotate in flexion (ruling out movement from other levels).


The range of rotation in end-range flexion is normally 40–44° to each side. Dysfunction approx 20°. It has high sensitivity (91%) and specificity (90%) in differentiating subjects with cervicogenic headaches from asymptomatic controls, or subjects with migraine with aura..


Ogince et al. The diagnostic validity of the cervical flexion-rotation test in C1/2 related cervicogenic headache. Man Ther 2007;12:256-262


Cervical Relocation Test

The patient begins seated, facing a wall 90 cm away, and wearing a head-mounted laser pointer that is centred on a target on the wall. The patient keeps their eyes closed while moving their neck in a specified direction, then back to what they believe to be centred starting position. The patient verbally indicates when they believe they are back to centre. The patient repeats this process for right rotation, left rotation, flexion, and extension (in no particular order).



The mean distance from the actual centre to the subjective centre is used to calculate the joint position error (JPE) for each movement. An error of 4.5° is the cut-off point suggesting a failure of head and neck relocation precision (< 4.5° – normal proprioception, > 4.5° – abnormal proprioception).


In summary, there are 3 main categories which all should be considered when compiling a treatment protocol.

1) Addressing altered cervical sensorimotor function

  • SMT, acupuncture, JPE retraining, cervical motor control (neuromuscular) exercises

2) Vestibular and Visual

  • eye-neck co-ordination exercises, gaze stabilization, VRT, oculomotor exercises (pursuit, saccades, OPK)

3) Balance and Posture Stability

  • ball, air disc, bosu, foam pads, tandem, eyes open/closed



If you would like to learn more about advanced protocols to manage the dizziness patient, we suggest you have a look at Brain Hub Academia’s course on dizziness here: