The effects of physiotherapy on neck pain with associated symptoms, including cervicogenic dizziness and tinnitus: a systematic review

Kübra Canlı; Indra De Greef; Eveline Van Looveren; Mira Meeus; Barbara Cagnie; Kayleigh De Meulemeester

doi:10.1186/s12891-026-09664-6

. 2026 Mar 9;27:244. doi: 10.1186/s12891-026-09664-6

The effects of physiotherapy on neck pain with associated symptoms, including cervicogenic dizziness and tinnitus: a systematic review

Kübra Canlı ^1,^✉,^#, Indra De Greef ^2,^3,^#, Eveline Van Looveren ⁴, Mira Meeus ^3,⁵, Barbara Cagnie ², Kayleigh De Meulemeester ^2,³

PMCID: PMC13019787 PMID: 41796312

Abstract

Objective

To systematically review the effectiveness of physiotherapy in people with neck pain and concurrent cervicogenic dizziness and/or tinnitus.

Methods

Database searches were performed in PubMed, Embase, Web of Science, and PEDro (Physiotherapy Evidence Database). The primary outcome was pain-related factors and secondary outcomes were self-reported measures of dizziness-, tinnitus- and psychological-related factors, and objective functional status in the short(< 3 months)-, intermediate(≥ 3 to < 12 months), and long-term(≥ 12 months). The population of interest was people with neck pain and concurrent cervicogenic dizziness and/or tinnitus. The literature search was conducted in December 2022, with an update in June 2024. Risk of bias was assessed using the revised Cochrane Risk of Bias Tool for randomized controlled trials, and the strength of the conclusion was assessed using the evidence-based guideline development (EBRO) approach. A narrative approach was conducted to synthesize the data.

Results

Thirteen studies (n = 785 patients) were analyzed, of which 10 were at high risk of bias, one raised some concers, and two were at low risk of bias. In the short-term, mulligan mobilization provided a higher improvement in CROM but showed no differences in balance with moderate evidence, and pain intensity and self-perceived handicap imposed by dizzines with conflicting evidence when compared to placebo treatment. Limited or no evidence was found for remaining pain-, dizziness, tinnitus- and psychological-related factors, and objective functional status after physiotherapy compared to wait-list or placebo treatment, and between different forms of physiotherapy.

Conclusion

The analysis of the literature revealed that most studies (10 studies; 77%) have overall poor methodologic quality and are at high risk of bias. Findings suggest that mulligan mobilization is more beneficial for CROM, but has similar effects on balance in the short term compared to placebo treatment. Further research would be needed to establish firm conclusions for intermediate- and longer‐term efficacy of physiotherapy, as well as its effect on pain-, tinnitus- and psychological-related factors, and objective functional status.

Trial registration

PROSPERO Registration Number: CRD42023394443.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-026-09664-6.

Keywords: Rehabilitation, Exercise therapy, Physical therapy modalities, Musculoskeletal manipulations, Sham treatment

Introductıon

Neck pain is one of the major musculoskeletal disorders in the adult population [1]. The lifetime prevalence of neck pain for the adult population across different countries has been reported to range from 14.2% to 71% based on geographical or regional differences [2] and is expected to grow hugely in the next decades [3]. Neck pain is often associated with dizziness and tinnitus [4, 5], with a prevalence estimated to be up to 93% [6] and 54.7 [7], respectively, leading to increased symptom severity and burden and, thus, poorer clinical recovery [8, 9].

One potential mechanism underlying the neck pain and concurrent cervicogenic dizziness and/or tinnitus is disturbed sensory information of the somatosensory system in the cervical region [9, 10]. The somatosensory system has a unique central and reflex interaction with the vestibular, visual, and auditory systems at different levels of the nervous system [11, 12]. The cervical somatosensory afferents are projected directly to the vestibular nucleus and superior colliculus, a reflex center for coordination between vision and neck movement, and transmitted to the central cervical nucleus through the dorsal root ganglion [11, 12]. The central cervical nucleus serves as a pathway to the cerebellum, where vestibular, ocular, and proprioceptive information is integrated, and to the cortex to sustain the body’s orientation [11, 12]. Disturbed somatosensory afferent information from the cervical region results in a sensory mismatch between vestibular and cervical inputs, leading to an inaccurate depiction of head and neck orientation in space and an illusory sensation of motion, also known as dizziness [12]. The cervical somatosensory afferents also provide information to the cochlear nucleus through the dorsal root ganglion and trigeminal ganglion, and other central auditory structures, including the inferior colliculus, and ultimately project into the auditory cortex [13]. Tinnitus is the result of correlated neural activity in the auditory pathway under 'no sound' conditions and distortion of the normal synaptic activity between the somatosensory and auditory brain areas [14]. Tinnitus is described as a conscious perception of an auditory sensation in the absence of a corresponding external stimulus [15].

Physiotherapy has been a widely accepted treatment to modify somatosensory afferent information through activation of the mechanosensitive, somatosensory receptors [16]. Therefore, physiotherapy is commonly used in clinical settings to decrease the severity of neck pain and, concurrent cervicogenic dizziness and tinnitus [17–30], indicating the necessity of building evidence-based physiotherapy practice to enable effective care. This makes it essential for physiotherapists to have a comprehensive understanding of the research in this field and to assess the strength of evidence supporting the effectiveness of physiotherapy for providing effective care. Yet, to date, previous systematic reviews mainly did not make a clear distinction between neck pain and concurrent cervicogenic dizziness or tinnitus, and cervicogenic dizziness or tinnitus, making it difficult to generalize the findings [23, 31–33]. Patients with neck pain and concurrent cervicogenic dizziness or tinnitus have significantly higher levels of symptoms compared to neck pain patients without dizziness or tinnitus [8, 9], indicating those with neck pain and concurrent cervicogenic dizziness or tinnitus may have a poor prognosis for recovery.

On the other hand, some systematic reviews shed light on manual therapy. De Vestel et al. (2022) found that manual therapy effectively improves the dizziness symptoms, pain, cervical range of motion, head repositioning accuracy, and sagittal alignment compared to sham therapy, no therapy or physiotherapeutic techniques (general physical activity, cervical spine exercises, multimodal cervical program, or traditional massage) in people with neck pain and concurrent cervicogenic dizziness with low to moderate quality of evidence [31]. Yaseen et al. showed that manual therapy provides greater improvement in dizziness symptoms compared to wait-list or placebo treatment with moderate evidence [34]. However, these reviews considered pain-related factors [31], objective functional status [31], and/or only dizziness-related factors [31, 34] as a clinical outcome measure but other clinical outcomes such as tinnitus-related factors and psychological-related factors were not included. Moreover, new randomised controlled trials in the field have been published since these published reviews, so an update with recent literature is desirable. Additionally, given the lack of evidence-based clinical guidelines specific to neck pain and concurrent cervicogenic dizziness or tinnitus, a systematic review of the existing literature would be of importance. Hence, this review aims to critically identify, appraise, and synthesize current evidence to create an overview of the effectiveness of physiotherapy in people with neck pain and concurrent cervicogenic dizziness or tinnitus to guide physiotherapists in clinical practice.

Materıals and methods

Protocol registration

This review was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO) with the registration number CRD42023394443 and reported following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines [35].

Research question

The research question addressed in this systematic review was formulated using the PICO model (P: Patient, I: Intervention, C: Control, O: Outcome) [36]; What is the effectiveness of physiotherapy (I) on pain-, dizziness-, tinnitus- and psychological-related factors, and objective functional status (O) in people with neck pain and concurrent cervicogenic dizziness or tinnitus (P)?

Information sources and search strategy

Four online databases, including PubMed [37], Embase [38], Web of Science [39] and Physiotherapy Evidence Database (PEDro) [40] were electronically searched to identify all studies concerning physiotherapy interventions in neck pain and associated symptoms of dizziness and tinnitus. Initial searches were carried out on December 19, 2022, with electronic database searches repeated on June 27, 2024. Grey literature was also searched to identify potential studies through Clinical trial record databases (ClinicalTrials.gov) and Open Grey.

The search strategy was based on a combination of the relevant Medical Subject Headings (MeSH) terms for PubMed, EMBASE Subject Headings (Emtree) terms for Embase, PEDro, and free-text words derived from the PICO question according to the requirements of each database Synonyms for P, I, and O were combined using the Boolean operator “OR” The Boolean operator “AND” was used to combine the terms P, I, and O to each other. Only randomized controlled trials (RCTs) were included in this review since RCTs are the best quality of studies to demonstrate the effect of an intervention by minimizing biases between intervention and control groups [41]. The search algorithm was adapted for each database as appropriate and is presented in Supplementary File 1.

No filters were applied. The search strategy was developed by the two review authors (I.D.G.) and (E.V.L.) authors, who, respectively, hold a Master's and Ph.D degree in Rehabilitation Sciences and Physiotherapy and are experienced in publishing systematic reviews for at least five years.

Eligibility criteria and study selection

All records resulting from the search strategy were imported into EndNote software and deduplicated. After deduplication, the remaining records were uploaded into Rayyan to screen titles/abstracts of the articles based on the pre-defined inclusion and exclusion criteria. Titles and abstracts were independently screened by the same two review authors (I.D.G.) and (E.V.L.) to identify relevant studies in a blinded, standardized manner. If any of the inclusion criteria were not met, the article was excluded. Likewise, in the second phase, the same two review authors independently screened the articles based on the full text. Any disagreement on title/abstract and full-text selection was resolved by discussion during a consensus meeting.

Inclusion criteria

Patients

Adult people (> 18 years) with (acute, recurrent, chronic) neck pain and concurrent cervicogenic dizziness and/or cervicogenic somatic tinnitus [11, 42].

Intervention

As far as we know, there have been no specific evidence-based physiotherapy guidelines for neck pain and concurrent cervicogenic dizziness or tinnitus. Therefore, intervention criteria were determined based on physiotherapy management for neck pain since it has been suggested that the management of cervicogenic dizziness or tinnitus is similar to that for neck pain [11, 43, 44]. Hence, physiotherapy interventions were primarily based on clinical practice guidelines for neck pain issued by the Orthopedic Section of the American Physical Therapy Association and systematic reviews performed by the Cochrane Network, the International Collaboration on Neck Pain, and the Neck Pain Task Force [45, 46].

Exclusion criteria

The following exclusion criteria were applied: studies on included children and adolescents (< 18 years); studies examining other than physiotherapeutic interventions; unavailability of full-text; articles in languages other than Dutch and English.

The detailed inclusion and exclusion criteria are listed in Table 1.

Table 1.

Inclusion and exclusion criteria for the selection of eligible articles

	Inclusion criteria	Exclusion criteria
Patients	People (> 18 years) with (acute, recurrent, chronic) neck pain and concurrent cervicogenic dizziness and/or cervicogenic somatic tinnitus	Children and adolescents (< 18 years) Animal studies No neck pain cervicogenic headache, fracture/dislocation, infections, other serious pathologies (cancer)
Intervention	1) manual therapy (including spinal mobilizations and manipulations), 2) myofascial release techniques including manual techniques and dry needling, 3) exercise therapy, 4) relaxation therapy, 5) ergonomic exercises/advise, 6) patient/pain education, 7) CBT, 8)…	Surgery Medication (Non-MTrP) acupuncture Other than physiotherapeutic interventions
Control group	1)Physiotherapeutic intervention (same as mentioned in “Intervention”), 2) Placebo/sham treatment, 3) control groups without treatment/wait and see	Surgery Medication (Non-MTrP) acupuncture Other than physiotherapeutic interventions No control group
Outcome measures	1) Self-perceived improvement of symptoms, 2) pain, dizziness and tinnitus parameters (such as intensity, duration and frequency), 3) questionnaires about pain or associated symptoms (Neck Disability Index, Tinnitus Handicap Inventory, Tinnitus Functional Index, Tinnitus Questionnaire,) 4) objective functional outcome measures (such as ROM, or strength, endurance, elasticity, stiffness, and other parameters related to objective functional outcome measures…), 5) psychological outcome measures (such as stress, depression, anxiety, kinesiophobia, catastrophizing, quality of life), 6) sleep (PSQI, ISI)	Other outcome measures
Study Design	Randomized controlled trials, clinical controlled trials	Case reports, case series, study protocols, case–control studies, cross-sectional studies systematic review, meta-analysis
Language	Dutch, English	Other languages
Other	Full text report available	Full text report not available

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CBT Cognitive Behavioral Therapy, ISI Insomnia severity index, MTrP Myofascial Trigger Point, PSQI Pittsburgh Sleep Quality Index, ROM Range of Motion, TTH Tension-type Headache

Outcome measures

Reliable, valid, and standardized clinical outcome measures used by physical therapists in general practice were selected as outcome measures [47–50]. The primary outcome was pain-related factors. The secondary outcomes were self-reported measures of dizziness-, tinnitus- and psychological-related factors, and objective functional status. The article that reported at least one of these secondary outcomes was included, even if it reported neither of the primary outcomes. Additionally, reported adverse events were of interest.

Data extraction

Relevant information was extracted from each included article and organized into an evidence table presenting the following (Supplementary File 2): 1) author and year of publication; 2) country and study design; 3) characteristics of the participants (sample size, gender, age); 4) characteristics of the intervention; 5) frequency and/or duration of the treatment; 6) length of follow‐up; 7) outcome measures; 8) main results of the outcome measures. Timing of the outcomes was classified as short-term follow-up when examined less than three months after randomization, intermediate follow-up for three months up to 12 months year, or long-term follow-up when studied 12 months or more after randomization [51]. If studies reported multiple time points within the same time period, the outcome closest to three months for short-term, six months for intermediate-term, and 12 months for long-term was considered. If the same authors published more than one study for the same purpose using the same population, either study with the largest sample size and most recent publication was included when the reports had conflicting results, or outcome measures were combined when the reports had consistent results to avoid double counting. However, if the same authors published multiple studies involving the same population but with distinct research purposes, all studies were included [52]. The data were obtained by the first author (K.C.), and a second author (I.D.G.) checked the extracted data. Any disagreement that arose was resolved during the discussion meeting.

Risk of bias

The revised Cochrane Collaboration risk-of-bias tool (RoB-2) was used to evaluate the risk of bias of the included randomized controlled trials by 2 independent authors (K.C and I.D.G.), both Ph.D candidates working with chronic musculoskeletal pain patients and experienced with writing systematic reviews The RoB-2 tool includes the following five domains: 1) bias arising from the randomization process; 2) bias due to deviations from the intended interventions; 3) bias due to missing outcome data; 4) bias in the measurement of the outcome; and 5) bias in the selection of the reported result. Each domain was scored in one of three categories: “high risk of bias,” “low risk of bias,” or “unclear”. The overall RoB for each study was classified as low risk of bias if all domains of the tool were judged “low risk of bias”, as some concerns if at least one domain of the tool was judged as “some concerns” but not as “high risk of bias” for any domain, or as high risk of bias if at least one domain of the tool was judged at “high risk of bias” [53]. Any disagreement was solved through discussion during a consensus meeting.

A level of evidence was determined according to the 2005 classification system of the Dutch Institute for Healthcare Improvement [36]. An “A2” classification was given to randomized controlled trials of good quality and of sufficient size and consistency. Randomized controlled trials of moderate quality or insufficient size were classified as “B.” Subsequently, a strength of conclusion 1 (high evidence) was given when there was one A1 study or at least two independent A2 studies. A strength of conclusion 2 (moderate evidence) was given when there was one A2 or at least 2 independently conducted studies of level B, whereas a strength of conclusion 3 (limited evidence) was given when there was one study of level B. The strength of conclusion 4 (conflicting evidence) was given in case of inconsistent or inconclusive studies of any level [36].

Data synthesis

The extracted data were presented in narrative form due to the high eneity between studies regarding the case definitions, methods of assessment, interventions and small sample sizes of the included studies, and in tabular form to provide a summary of the findings. Data pertinent to research question and reporting one of the outcomes related to pain-, dizziness-, tinnitus-, psychological-related factors, or objective functional status were extracted. The results were grouped by outcome measures and the timing of the outcomes.

Effect sizes were extracted seperately for individual studies when reported or alternatively calculated where data were available, and not pooled across studies. Effect sizes were determined by calculating them separately within the intervention and control groups (obtaining the difference between baseline and post-treatment means, divided by the within-group standard deviation at baseline) and then subtracting the control group’s effect size from that of the intervention group. For studies that reported a standard error but no standard deviation, the standard error was converted to a standard deviation using the formula: standard deviation = standard error* Inline graphic Effect sizes were interpreted based on Cohen’s d effect size index, characterized as follows: 0.20–0.49, small effect size; 0.50–0.79, moderate effect size; and ≥ 0.80, large effect size.

The minimal clinically important differences (MCIDs) were reported for pain intensity (Visual Analog Scale _0–100 mm = varied between 14.4 to 21.4 mm; Numerical Rating Scale _{0–10 point} = 4 point) [54, 55], self-perceived neck pain and disability (Neck Pain and Disability questionnaire _{0–50 point} = 5 points) [56], self-perceived handicap imposed by dizziness (Dizziness Handicap Inventory questionnaire _{0–100 point} = 18 points) [49], and cervical range of motion (CROM flexion–extension = 4–6°; CROM rotation = 5–10°) [57] in the literature. No minimal clinically important differences are known for the other outcome measures.

Results

Study selection

The initial search identified 8994 articles. After removing the duplicates, 6620 articles were screened on title and abstract. Of these, 178 articles were identified as potentially eligible. After a full-text analysis, 163 of the remaining full-text articles did not meet the inclusion criteria and were excluded because of the wrong population, study design, wrong intervention, outcomes, and no full text available. As a result, a total of 14 articles met the inclusion criteria. Of these, two articles reported on the same study and included the same population, outcome measures and follow-up periods. the oldest article with the smallest sample size was excluded [18]. Finally, 13 articles included in this review. The flow chart depicting the number of studies at each phase of the screening process and the reasons for exclusion are demonstrated in Fig. 1.

Fig. 1 — The flow chart depicting the number of studies at each phase of the screening process and the reasons for exclusion

Study characteristics

The study design of the included articles was a cross-over RCT for one study [22], parallel randomized controlled trials with two groups for eight studies [21, 24, 25, 27–29, 58, 59], and parallel randomized controlled trials with three groups for four studies [17, 19, 20, 60].

Twelve studies included people with neck pain and concomitant dizziness [17, 19–21, 24, 25, 27–29, 58–60], and one study included patients with neck pain and concomitant tinnitus [22]. The number of patients in each study varied from 17 [25] to 86 [17, 19, 20]. The mean age of the patients ranged from 39.3 ± 2.5 years [60] to 65.6 ± 11.0 years [17, 20]. Twelve studies recruited both women and men [17, 19–22, 24, 25, 27, 28, 58–60], and one study recruited only women [29]. Eight studies reported symptom duration as chronic (> three months’ duration) [17, 19–22, 24, 29, 60], but five studies did not mention the symptom duration [25, 27, 28, 58, 59]. The length of the provided intervention varied from one week [27, 28, 59] to five months [25], and the frequency of therapy varied from once every three weeks [17, 19, 20] to five times a week [29]. The length of the follow-up assessments ranged from four weeks [27, 28, 59, 60] to 12 months [19, 21, 58] after the intervention. The characteristics of the included studies are reported in Supplementary File 2.

Outcome measures

The most assessed outcome measures were pain intensity (8/13 studies; 61.5%) [17, 19, 21, 24, 25, 27, 29, 59] for pain-related factors and self-perceived handicap imposed by dizziness (10/13 studies; 76.9%) [17, 19, 21, 24, 27–29, 58–60] for dizziness-related factors. The Dizziness Handicap Inventory was reported as measuring the quality of life but appraised as a self-perceived handicap imposed by dizziness in this review [29, 60]. The Global Rating of Change was reported as the perceived amount of recovery, but appraised as perceived benefit from the intervention for subjective complaints associated with dizziness [27].

Tinnitus- [22] and psychological-related factors [24] were investigated by only one study.

CROM [19, 20, 24, 27, 59, 60] and balance[19, 20, 25, 27]were the most assessed outcomes for objective functional status. Posturography was reported as postural performance in one study but interpreted as balance in this review [25].

The details of the outcome measures and the assessment methods were shown in Supplementary File 3.

Interventions

Nine of the 13 studies included one intervention and one control group [21, 22, 24, 25, 27–29, 58, 59]. The remaining four studies included two intervention groups and one control group [17, 19, 20, 60]. Details of the specific physiotherapy interventions evaluated can be found in Supplementary File 2.

Risk of bias

The risk of bias results (per domain and overall risk of bias rating) for included studies are shown in Table 2. The agreement between the two raters was 88.5% (292 of 330 items) regarding the risk of bias score of the selected articles. During a consensus meeting, the remaining 38 items were discussed between the two raters, and consensus was reached for all disagreements without the need for a third opinion. Overall, the risk of bias of the included studies was scored to be high in ten studies [17, 19, 21, 22, 25, 27–29, 58, 60], some concerns in one study [20], and low in two studies [24, 59].

Table 2.

The risk of bias results (per domain and overall risk of bias rating) for included studies

Studies	Randomization process	Intended intervention	Missing outcome data	Measurement of the outcome	Reported results	Overal
Aydın et al. [29]	some concerns	high	high	high	low	high
Carrasso-Uribarren et al. [27]	low	some concerns	low	high	some concerns	high
Carrasso-Uribarren et al. [28]	low	some concerns	low	high	some concerns	high
Carrasso-Uribarren et al. [59]	low	low	low	low	low	low
Karlberg et al. [25]	some concerns	some concerns	low	high	some concerns	high
Micarelli et al. [24]	low	low	low	low	low	low
Michiels et al. [22]	some concerns	low	low	high	high	high
Mohamed et al. [60]	low	low	low	some concerns	some concerns	high
Moustafa et al. [21]	low	low	low	high	low	high
Reid et al. [17]	low	low	high	low	low	high
Reid et al. [19]	low	some concerns	high	low	low	high
Reid et al. [20]	low	some concerns	low	low	low	some concerns
Svensson et al. [58]	low	low	some concerns	some concerns	high	high

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One study rated a “high risk of bias” [29], and one study rated “some concerns” bias due to deviation from intended intervention [20] since they did not provide information about the co-interventions [20, 29] and one of them did not conduct an intention to treat analysis [29]. Three studies rated a “high risk of bias” due to missing outcome data since studies did not clearly document reasons for missing values in the outcome data, which could possibly be related to its true value [17, 19, 29]. Eight studies rated a “high risk of bias” due to measurement of the outcome since they did not use blinding of the participants and/or outcome assessors, and they relied on patient-reported outcomes in which assessment of the outcome can be influenced by knowledge of the intervention received [21, 22, 25, 27–29, 58, 60]. Three studies rated a “high risk of bias” due to selective non-reporting of the outcomes [22, 58].

Level of evidence

The level of evidence was rated B in 13 studies due to a lack of blindness [17, 19–22, 24, 25, 27–29, 58–60] and/or insufficient sample size or power [25]. The level of evidence for each outcome was summarized to estimate its effect on each outcome in a structured format and to increase transparency, accuracy, and completeness of reporting judgment in the level of evidence assessment in Table 3.

Table 3.

The level of evidence for each outcome

Outcomes	Study	Results of each study
Outcomes	Study	RoB	ST	Conclusion LoE	IT	Conclusion LoE	LT	Conclusion LoE
Mulligan mobilization (G1) versus wait-list or placebo treatment (G2)
Pain-related factors
Pain intensity	Micarelli et al., [24]	B	G1>G2	G1=G2 conflicting evidence
	Reid et al., [17]	B	G1=G2	G1=G2 conflicting evidence	G1=G2	G1=G2 limited evidence
	Reid et al., [19]	B					G1=G2	G1=G2 limited evidence
Self-perceived neck pain and disability	Micarelli et al., [24]	B	G1>G2 MDs	G1>G2 limited evidence
Dizziness-related factors
Dizziness intensity	Reid et al., [17]	B	G1>G2	G1>G2 limited evidence	G1>G2	G1=G2 limited evidence
Dizziness intensity	Reid et al., [19]	B					G1=G2	G1=G2 limited evidence
Dizziness frequency	Reid et al., [17]	B	G1=G2	G1=G2 limited evidence	G1>G2	G1=G2 limited evidence
Dizziness frequency	Reid et al., [19]	B					G1>G2	G1>G2 limited evidence
Self-perceived handicap imposed by dizziness	Micarelli et al., [24]	B	G1>G2	G1=G2 conflicting evidence
	Reid et al., [17]	B	G1=G2	G1=G2 conflicting evidence	G1=G2	limited evidence
	Reid et al., [19]	B					G1>G2	G1>G2 limited evidence
Perceived benefit from the intervention for subjective complaints associated with dizziness	Reid et al., [17]	B	G1>G2	G1>G2 limited evidence	G1>G2	G1>G2 limited evidence
	Reid et al., [19]	B					G1>G2	G1>G2 limited evidence
Psychological-related factors
Fear of movement	Micarelli et al., [24]	B	G1>G2	G1>G2 limited evidence
Anxiety and depression	Micarelli et al., [24]	B	G1>G2	G1>G2 limited evidence
Objective functional status
CROM	Micarelli et al., [24]	B	F, E, right/left LFx, right/left rotation G1>G2	F, E, right/left LFx, right/left rotation G1>G2 moderate evidence
	Reid et al., [20]	B	F, E, right/left LFx, right/left rotation G1>G2		F, E, right LFx, right/left rotation G1>G2 left LFx; G1=G2	F, E, right LFx, right/left rotation G1>G2 limited evidence left LFx; G1=G2 limited evidence
	Reid et al., [19]	B					6/6 dir.; G1>G2	G1>G2 limited evidence
HRA	Reid et al., [20]	B	right/left rotation; G1=G2	right/left rotation; G1=G2 limited evidence	right rotation; G1=G2 left rotation; G1<G2	right rotation; G1=G2 limited evidence left rotation; G1<G2 limited evidence
HRA	Reid et al., [19]	B					right/left rotation; G1=G2	right/left rotation; G1=G2 limited evidence
Balance	Micarelli et al., [24]	B	4/11 param.; G1>G2 7/11 param.; G1=G2	G1=G2 moderate evidence
	Reid et al., [20]	B	1/6 param.; G1>G2 5/6 param.; G1=G2	G1=G2 moderate evidence	6/6 dir.; G1=G2	G1=G2 limited evidence
	Reid et al., [19]	B					1/6 param.; G1>G2 5/6 param.; G1=G2	G1=G2 limited evidence
Multimodal manual therapy (G1) versus wait-list or placebo treatment (G2)
Pain-related factors
Pain intensity	Carrasso-Uribarren et al., [27] Carrasco-Uribarren et al., [59]	B	G1>G2G1=G2	G1=G2 conflicting evidence
Pain sensitivity	Carrasso-Uribarren et al., [28]	B	2/6 sites; G1>G24/6 sites; G1=G2	G1=G2 limited evidence
Self-perceived neck pain and disability	Carrasso-Uribarren et al., [28]	B	G1>G2 MDs	G1>G2 limited evidence
Dizziness-related factors
Dizziness intensity	Carrasso-Uribarren et al., [27]Carrasso-Uribarren et al., [28]Carrasco-Uribarren et al., [59]	B	G1>G2	G1>G2 limited evidence
Self-perceived handicap imposed by dizziness	Carrasso-Uribarren et al., [27]Carrasso-Uribarren et al., [28]Carrasco-Uribarren et al., [59]	B	G1>G2MDs	G1>G2limitedevidence
Perceived benefit from the intervention for subjective complaints associated with dizziness	Carrasco-Uribarren et al., [27]	B	G1>G2	G1>G2 limited evidence
Objective functional status
Upper CROM	Carrasso-Uribarren et al., [27]	B	F; G1=G2 E; G1>G2	G1>G2 limited evidence F; G1=G2 E; G1>G2 Most and less restricted direction; G1>G2 Global upper CROM; G1=G2 limited evidence
	Carrasco-Uribarren et al., [28]	B	Most and less restricted direction; G1>G2
	Carrasco-Uribarren et al., [59]	B	1/1 dir.; G1=G2 Global upper CROM; G1=G2
CROM	Carrasco-Uribarren et al., [27]	B MDs	F, E, right/left LFx, left rotation; G1=G2 Right rotation G1>G2	F, E, right/left LFx, left rotation; G1=G2 limited evidence Right rotation G1>G2 limited evidence Total CROM in sagittal and frontal plane, global CROM; G1>G2 limited evidence Total CROM in transvers plane; G1=G2 limited evidence
CROM	Carrasco-Uribarren et al., [59]		Total CROM in sagittal and frontal plane, and global CROM; G1>G2 Total CROM in transvers plane; G1=G2
Balance	Carrasco-Uribarren et al., [27]	B	1/12 param.²; G1>G2 11/12 param.²; G1=G2	G1=G2 limited evidence
Multimodal physiotherapy (G1) versus wait-list or placebo treatment (G2)
Pain-related factors
Pain intensity	Karlberg et al., [25]	B	G1>G2	G1>G2 limited evidence
Self-perceived neck complaints severity	Michiel at al., [22]	B	G1>G2	G1>G2 limited evidence	G1=G2	G1=G2 limited evidence
Dizziness-related factors
Dizziness intensity	Karlberg et al., [25]	B	G1>G2	G1>G2 limited evidence
Dizziness frequency	Karlberg et al. [25]	B	G1=G2	G1=G2 limited evidence
Tinnitus annoyance	Michiel at al., [22]	B	G1=G2	G1=G2 limited evidence	G1=G2	G1=G2 limited evidence
Perceived benefit from the intervention for subjective complaints associated with tinnitus	Michiel et al., [22]	B	G1>G2	G1>G2 limited evidence
Objective functional status
Balance	Karlberg et al., [25]	B	9/29 param.; G1>G2 20/29 param.; G1=G2	G1>G2 limited evidence
Pain intensity	Reid et al., [17]	B	G1=G2	G1=G2 limited evidence	G1>G2	G1>G2 limited evidence
Pain intensity	Reid et al., [19]	B					G1=G2	G1=G2 limited evidence
Dizziness-related factors
Dizziness intensity	Reid et al. [17]	B	G1>G2	G1>G2 limited evidence	G1>G2	G1>G2 limited evidence
Dizziness intensity	Reid et al., [19]	B					G1=G2	G1=G2 limited evidence
Dizziness frequency	Reid et al., [17]	B	G1=G2	G1=G2 limited evidence	G1>G2	G1>G2 limited evidence
Dizziness frequency	Reid et al., [19]	B					G1>G2	G1>G2 limited evidence
Self-perceived handicap imposed by dizziness	Reid et al., [17]	B	G1>G2	G1>G2 limited evidence	G1>G2	G1>G2 limited evidence
Self-perceived handicap imposed by dizziness	Reid et al., [19]	B					G1>G2	G1>G2 limited evidence
Perceived benefit from the intervention for subjective complaints associated with dizziness	Reid et al., [17]	B	G1>G2	G1>G2 limited evidence	G1>G2	G1>G2 limited evidence
	Reid et al., [19]	B					G1>G2	G1>G2 limited evidence
Objective functional status
CROM	Reid et al., [20]	B	F, E, right/left LFx, right rotation, G1=G2 left rotation G1>G2	F, E, right/left LFx, right rotation, G1=G2 limited evidence left rotation G1>G2 limited evidence	F, E, left rotation, right/left LFx G1=G2 right rotation G1>G2	F, E, left rotation, right/left LFx G1=G2 limited evidence right rotation G1>G2 limited evidence
CROM	Reid et al., [19]	B					F, E, left/right rotation, left/rigt rotation G1>G2	F, E, left/right rotation, left/rigt rotation G1>G2 limited evidence
HRA	Reid et al., [20]	B	right rotation; G1=G2 left rotation; G1<G2	right rotation; G1=G2 limited evidence left rotation; G1<G2 limited evidence	left rotation, right rotation; G1=G2	G1=G2 limited evidence
HRA	Reid et al., [19]	B					right/left rotation; G1=G2	right/left rotation; G1=G2 limited evidence
Balance	Reid et al., [20]	B	1/6 param.; G1>G2 5/6 param.; G1=G2	G1=G2 limited evidence	6/6 param.; G1=G2	G1=G2 limited evidence
Balance	Reid et al., [19]	B					1/6 param.; G1>G2 5/6 param.; G1=G2	G1=G2 limited evidence
Studies comparing two physiotherapy interventions
Exercise + dry needling (G1) versus exercise (G2)
Pain intensity	Aydın et al. [29]	B	G1>G2	G1>G2 limited evidence	G1>G2	G1>G2 limited evidence
Pain sensitivity	Aydın et al., [29]	B	G1=G2	G1=G2 limited evidence	G1>G2	G1>G2 limited evidence
Dizziness-related factors
Dizziness frequency	Aydın et al., [29]	B	G1>G2	G1>G2 limited evidence	G1=G2	G1>G2 limited evidence
Self-perceived handicap imposed by dizziness	Aydın et al., [29]	B	G1>G2	G1>G2 limited evidence	G1>G2	G1>G2 limited evidence
Maitland mobilization + electrotherapy modalities (G1) versus electrotherapy modalities (G2)
Pain intensity	Moustafa et al., [21]	B	G1=G2	G1=G2 limited evidence			G1>G2	G1>G2 limited evidence
Dizziness-related factors
Dizziness intensity	Moustafa et al., [21]	B	G1=G2	G1=G2 limited evidence			G1>G2	G1>G2 limited evidence
Dizziness frequency	Moustafa et al., [21]	B	G1=G2	G1=G2 limited evidence			G1>G2	G1>G2 limited evidence
Self-perceived handicap imposed by dizziness	Moustafa et al., [21]	B	G1=G2	G1=G2 limited evidence			G1>G2	G1>G2 limited evidence
Objective functional status
AHT	Moustafa et al., [21]	B	G1>G2	G1>G2 limited evidence			G1>G2	G1>G2 limited evidence
ARA	Moustafa et al., [21]	B	G1>G2	G1>G2 limited evidence			G1>G2	G1>G2 limited evidence
HRA	Moustafa et al., [21]	B	right/left rotation; G1=G2	right/left rotation; G1=G2 limited evidence			right/left rotation; G1>G2	right/left rotation; G1>G2 limited evidence
Maitland mobilization + exercise (G1) versus Mulligan mobilization (G2)
Pain intensity	Reid et al., [17]	B	G1=G2	G1=G2 limited evidence	G1=G2	G1=G2 limited evidence
Pain intensity	Reid et al., [19]	B					G1=G2	G1=G2 limited evidence
Dizziness-related factors
Dizziness intensity	Reid et al., [17]	B	G1=G2	G1=G2 limited evidence	G1=G2	G1=G2 limited evidence
Dizziness intensity	Reid et al., [19]	B					G1=G2	G1=G2 limited evidence
Dizziness frequency	Reid et al. [17]	B	G1=G2	G1=G2 limited evidence	G1=G2	G1=G2 limited evidence
Dizziness frequency	Reid et al., [19]	B					G1=G2	G1=G2 limited evidence
Self-perceived handicap imposed by dizziness	Reid et al., [17]	B	G1=G2	G1=G2 limited evidence	G1>G2	G1>G2 limited evidence
Self-perceived handicap imposed by dizziness	Reid et al., [19]	B					G1=G2	G1=G2 limited evidence
Perceived benefit from the intervention for subjective complaints associated with dizziness	Reid et al., [19]	B					G1=G2	G1=G2 limited evidence
Objective functional status
CROM	Reid et al., [20]	B	F, right/left LFx, left rotation; G1=G2 E, right rotation; G2>G1	F, right/left LFx, left rotation G1=G2 limited evidence E, right rotation; G2>G1 limited evidence	F, E, right/left LFx, right/left rotation; G1=G2	F, E, right/left LFx, right/left rotation; G1=G2 limited evidence
CROM	Reid et al., [19]	B					F, E, right/left LFx, right/left rotation; G1=G2	F, E, right/left LFx, right/left rotation; G1=G2 limited evidence
HRA	Reid et al., [20]	B	right/left rotation; G1=G2	right/left rotation G1=G2 limited evidence	right rotation; G1=G2 left rotation; G1>G2	right rotation; G1=G2 limited evidence left rotation; G1>G2 limited evidence
HRA	Reid et al., [19]	B					right/left rotation; G1=G2	G1=G2 limited evidence
Balance	Reid et al., [20]	B	5/6 param.; G1=G2 1/6 param.; G2>G1	G1=G2 limited evidence	6/6 param.; G1=G2	G1=G2 limited evidence
Balance	Reid et al., [19]	B					6/6 param.; G1=G2	G1=G2 limited evidence
Self-perceived neck pain and disability	Mohamed et al., [60]	B	G3>G1 = G2	G3>G1 = G2 limited evidence
Dizziness-related factors
Self-perceived handicap imposed by dizziness	Mohamed et al., [60]	B	G2>G1 G1=G3 G2=G3	G2>G1 G1=G3 G2=G3 limited evidence
Objective functional status
Upper CROM	Mohamed et al., [60]	B	G3>G1=G2	G3>G1=G2 limited evidence
Dizziness-related factors
Self-perceived handicap imposed by dizziness	Svensson et al., [58]	B			G1=G2	G1=G2 limited evidence	G1=G2	G1=G2 limited evidence

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AHT Anterior Head Translation, ARA Absolute Rotation Angle of Cervical Lordosis, C Cervical Spine, CROM Cervical Range of Motion E Extension, F Flexion, G Group, HRA Head Repositioning Accuracy, IT Intermediate-Term Follow-up Outcomes, LFx Lateral Flexion, LoE Level of Evidence, LT Long-Term Follow-up Outcomes, param Parameters, NR Not Reported, Rob Risk of Bias, SNAGs Sustained Natural Apophyseal Glides, ST Short-Term Follow-up Outcomes, > Significantly Improved More Than, < Significantly Improved Less Than, = No Significant Differences

¹Results for 48 Hours After the Intervention

²Results for One Month After the Intervention

Results of individual studies

The results of each study were detailed in Supplementary File 2 and Table 3, and summarized as follows:

Studies comparing one physiotherapy intervention with a placebo or wait-list
- Mulligan mobilization versus wait-list or placebo treatment
  - Pain-related factors
    
    Evidence on pain intensity in the short-term [17, 19, 24], intermediate-term [17], long-term [19], and self-perceived neck pain and intensity in the short-term [24]was conflicting and limited, with effect size ranging from small to large. Mean differences for pain-related factors approached their respective MCIDs only for pain intensity in the intermediate-term (mean differences: −14.2(−27.5 to −1), d: 0.6, p: 0.04) [17].
  - Dizziness-related factors
    
    Evidence on dizziness intensity, dizziness frequency, self-perceived handicap imposed by dizziness, perceived benefit from the intervention for subjective complaints associated with dizziness was conflicting and limited in the short-term, intermediate-term and the long-term, with effect size ranging from small to large [17, 19, 24]. Mean differences for self-perceived handicap imposed by dizziness does not exceed its respective MCIDs [17, 19, 24].
  - Psychological-related factors
  - Evidence on fear of movement, anxiety, and depression was limited for the short-term [24] with a small effect size
  - Objective functional status
    
    Moderate evidence showed that mulligan mobilization led to a significantly higher increase in CROM compared to placebo treatment in the short-term with a small to large effect size [20, 24], and in the intermediate-term and long-term with a small effect size [20]. Mean differences for CROM in all directions in the short-term, intermediate-term and long-term exceed their respective MCIDs [20, 24]. There were no significant differences between the groups regarding changes in balance in the short-term with moderate evidence [20, 24]. Mulligan mobilization and placebo treatment provides similar changes in head repositiong accuracy in the short-term, intermediate-term and the long-term with a small effect size [19, 20].
- Multimodal manual therapy (Suboccipital muscle massage + high-speed low amplitude traction manipulation C0-C1, C1-C2, C2-C3 + remained relaxed in the supine position for one minute) versus wait-list or placebo treatment
  - Pain-related factors
    
    Evidence on pain intensity [27, 59], pain sensitivity [28], and self-perceived neck pain and disability [28] was limited in the short-term, with effect size ranging from small to large. Although mean differences for pain intensity does not exceed their respective MCIDs [27, 59], Mean differences for self-perceived neck pain and disability (50 point NDI, mean differences: 5.6(−12.2 to −1.93), d: 0.9, p < 0.012) exceed their respective MCIDs [28].
  - Dizziness-related factors
    
    Limited evidence was found that multimodal manual therapy provided a significantly higher decrease in dizziness intensity and self-perceived handicap imposed by dizziness after multimodal manual therapy compared to placebo treatment in the short-term with a large effect size [27, 28, 59]. Mean differences for self-perceived handicap imposed by dizziness (100 point Dizziness Handicap Inventory questionnaire, mean differences: −18.8(−28 to −9.5), d: 0.9, p < 0.001) exceed its respective MCIDs [59]. There was no evidence for dizziness-related factors in the intermediate-term and long-term.
  - Objective functional status
    
    Evidence on upper CROM [27, 28, 59], CROM [59], and balance [27] was limited in the short-term, with effect size ranging from small to large. Mean differences for CROM in all directions exceed their respective MCIDs [59].
- Multimodal physiotherapy (soft tissue treatment + passive/active mobilization + relaxation techniques + exercises + home training program + minor ergonomic changes at work or manual mobilization + exercise + home exercises) versus wait-list or placebo treatment
  - Pain-related factors
    
    Evidence on pain intensity in the short-term [25] and self-perceived neck complaints severity in the short-term [22] and intermediate-term [22] was limited with effect size ranging from small to large. Mean differences for pain intensity (100 mm VAS, mean differences: 22, d: 0.9, p < 0.05) exceed its respective MCIDs [25].
  - Dizziness-related factors
    
    Evidence on dizziness intensity [25] and dizziness frequency [25] was limited for the short-term.
  - Tinnitus-related factors
    
    There was limited evidence for tinnitus annoyance in the short-term and in the intermediate-term, and for perceived benefit from the intervention for subjective complaints associated with tinnitus in the short-term [22].
  - Objective functional status
    
    Evidence on balance was limited for the short-term [25].
- Maitland mobilizations + exercise versus wait-list or placebo treatment
  - Pain-related factors
    
    Evidence on pain intensity was limited for the short-term [17], intermediate-term [17], and long-term [19] with a small effect size. Mean differences for pain intensity does not exceed its respective MCIDs [17, 19].
  - Dizziness-related factors
    
    Evidence on dizziness intensity, dizziness frequency, self-perceived handicap imposed by dizziness, perceived benefit from the intervention for subjective complaints associated with dizziness was limited in the short-term, intermediate-term, and long-term, with effect size ranging from small to large [17, 19]. Mean differences for self-perceived handicap imposed by dizziness does not exceed its respective MCIDs [17, 19].
  - Objective functional status
    
    Evidence on cervical range of motion, head repositioning accuracy, and balance was conflicting and limited for the short-term, the intermediate-term, and the long-term with a small effect size [19, 20]. Mean differences for CROM of the flexion/extension/left rotation in the short-term, flexion/right rotation in the intermediate-term, and in all direction in the long-term exceed their respective MCIDs [19, 20].
Studies comparing two physiotherapy interventions
- Exercise + dry needling versus exercise
  - Pain-related factors
    
    Evidence on pain intensity and pain sensitivity was limited for the short-term and intermediate-term [29] with a small effect size. Mean differences for pain intensity does not exceed its respective MCIDs [29].
  - Dizziness-related factors
    
    Evidence on dizziness frequency and self-perceived handicap imposed by dizziness was limited for the short-term and intermediate-term with a small effect size [29].
- Maitland mobilization + electrotherapy modalities versus electrotherapy modalities
  - Pain-related factors
    
    Evidence on pain intensity was limited for the short-term with a small effect size and for the long-term with a large effect size [21]. Mean differences for pain intensity does not exceed its respective MCIDs in the short-term and long-term [21].
  - Dizziness-related factors
    
    Evidence on dizziness intensity, dizziness frequency, self-perceived handicap imposed by dizziness was limited for the short-term and long-term with a large effect size [21]. Mean differences for self-perceived handicap imposed by dizziness in the long-term (100 point Dizziness Handicap Inventory questionnaire, mean differences: 29.9 (−34.4 to −29.9), d: 2.9, p < 0.005) exceed its respective MCIDs [21].
  - Objective functional status
    
    Evidence on anterior head translation, absolute rotation angle of cervical lordosis, head repositioning accuracy was limited for the short-term, and the long-term with a large effect size [21].
- Maitland mobilization + exercise versus Mulligan mobilization
  - Pain-related factors
    
    Evidence on pain intensity was limited for the short-term with a small effect size, intermediate-term with a moderate effect size, and the long-term with a small effect size [17, 19]. Mean differences for pain intensity does not exceed its respective MCIDs in the short-term, intermediate term and long-term [17, 19].
  - Dizziness-related factors
    
    Evidence on dizziness intensity, dizziness frequency, self-perceived handicap imposed by dizziness, and perceived benefit from the intervention for subjective complaints associated with dizziness was limited in the short-term, intermediate-term and the long-term with a small to large effect size [17, 19]. Mean differences for self-perceived handicap imposed by dizziness does not exceed its respective MCIDs [17, 19].
  - Objective functional status
    
    Evidence on CROM, head repositioning accuracy and balance was limited for the short-term, intermediate-term and the long-term with a small effect size [19, 20]. Mean differences for CROM of the extension/right rotation in the short-term, extension in the intermediate-term, in the long-term exceed their respective MCIDs [19, 20].
- C2 headache Mulligan Sustained Natural Apophyseal Glide mobilisation versus C1-C2 rotational Mulligan Sustained Natural Apophyseal Glide mobilization versus C2 headache + C1-C2 rotation Mulligan Sustained Natural Apophyseal Glide mobilisation
  - Pain-related factors
    
    Evidence on self-perceived neck pain and disability was limited for the short-term with a large effect size [60]. Mean differences for self-perceived neck pain and disability does not exceed its respective MCIDs [60].
  - Dizziness-related factors
    
    Evidence on self-perceived handicap imposed by dizziness was limited for the short-term with a large effect size [60]. Mean differences for self-perceived handicap imposed by dizziness does not exceed its respective MCIDs [60].
  - Objective functional status
    
    Evidence on upper cervical range of motion was limited for the short-term with a large effect size [60].
- Neck-specific exercise versus prescribed physical activity
  - Dizziness-related factors
    
    Evidence on self-perceived handicap imposed by dizziness was limited for the intermediate-term, and long-term with a small effect size [58]. Mean differences for self-perceived handicap imposed by dizziness does not exceed its respective MCIDs [58].

Adverse events

Three studies did not mention the presence or absence of treatment-related adverse effects [25, 29, 60]. Eight studies did not report any adverse effects during the course of the study [20–22, 24, 27, 28, 58, 59]. Two studies reported that adverse effects did not last longer than 24 h after any of the interventions [17, 19]. One of them reported mild transient pain in the lower cervical spine or upper arm after mulligan mobilization [17], whereas the other study did not specify the adverse effects [19].

Discussion

This systematic review aimed to identify, appraise, and synthesize current evidence to create an overview of the effectiveness of physiotherapy on neck pain and concurrent dizziness or tinnitus by critically evaluating all available randomized controlled trials. It is important to take the risk of bias into consideration when evaluating the evidence of an intervention based on this review. The level of evidence for most of the included outcomes ranged from conflicting to limited evidence after physiotherapy compared to wait-list or placebo treatment in people with neck pain and concurrent cervicogenic dizziness or tinnitus. However, this does not necessarily imply that physiotherapy has no effect on these outcomes, only that the present evidence is not sufficient. Moreover, the efficacy of one form of physiotherapy compared to another form of physiotherapy has limited evidence, indicating low reliability. Details about all levels of conclusions are discussed below and presented in Table 3.

When comparing physiotherapy and wait-list or placebo treatment in people with neck pain and concurrent cervicogenic dizziness or tinnitus, the findings of this review indicates that: a) there were clinically relevant reduction of pain intensity in the intermediate-term based on MCIDs and greater improvements in CROM in the short-term, but no differences in balance in the short-term after mulligan mobilization compared to wait-list or placebo treatment. b) there were clinically relevant reduction of self-perceived neck pain and disability and self-perceived handicap imposed by dizziness, and clinically relevent improvement in CROM after multimodal manual therapy compared to wait-list or placebo treatment in the short-term. c) there were clinically relevant reduction of pain intensity in the short-term after multimodal physiotherapy and clinically relevant improvement of CROM in the short-term, intermediate-term and long-term after maitland mobilizations + exercise compared to wait-list or placebo treatment.

Evidence for pain- dizziness-related factors, and objective functional status comes from the studies that include mobilization/manipulation of the upper cervical spine (occiput-C3) on its own or a part of multimodal physiotherapy from three sessions in a one week [27, 28] to once a week for 6–20 weeks [17, 25] in this review. Manual therapy (both mobilization and manipulation) targeting the upper cervical spine has been known to normalize somatosensory afferent information from the cervical zygapophyseal joint of C1 to C3 and reduce muscle spasms, particularly in the suboccipital muscles since these group of muscles located between the occiput, C1, and C2 [61, 62]. The upper cervical spine provides dense somatosensory afferent information to the central nervous system since joint capsules of C1–C3 contain 50% of all cervical proprioceptors, and suboccipital muscles have a higher density of muscle spindles compared to superficial cervical muscles [63]. Thus, normalized cervical somatosensory afferent information might reduce the sensory mismatch between the somatosensory, vestibular, and visual afferent information and coordinate cervical reflex connections to the vestibular and vestibular systems to maintain the coordinated movement of the head, eyes, neck, and body [12]. These processes might subsequently result in improvement in pain- dizziness-related factors. Normalized somatosensory afferent information of the suboccipital muscle may also resulted in increased CROM by leading to suboccipital muscles to have better control the motion between occiput, C1 and C2. It has been known that the upper cervical spine (C0–C2) is responsible for 50% of total neck flexion and extensions and for 50% of overall cervical rotation [64].

Limited evidence is available regarding tinnitus-related factors. This is not surprising when considering the effects of pain-related factors on tinnitus-related factors due to the fact that painful stimuli from the neck could increase the activity of the cochlear nucleus in the auditory pathways, ultimately influencing tinnitus-related factors [65]. Although high-quality guidelines support physiotherapy for the management of pain-related factors in people with neck pain [66], we could not compare our results with them. Because, it has been shown that people with neck pain and concomitant dizziness or tinnitus have a higher incidence of the presence and severity of self-reported signs of central sensitization, and increased levels of pain intensity, disability, and psychological symptoms compared to people with neck pain without concomitant dizziness or tinnitus [8, 67]. However, our results are consistent with a systematic review performed by Michiels et al., who showed that physiotherapy provides significantly higher decreases in tinnitus intensity and severity compared to the control group, which consisted of the wait-list, placebo treatment, or physiotherapy, in a mixed population of cervicogenic tinnitus people with pain complaints in the head, neck or shoulder girdle and without neck pain, with low evidence [23]. More evidence is still required in this field.

Balance involves complex neural interaction among the visual systems, vestibular systems, and somatosensory systems, particularly in proprioception [68]. It has been shown that the effect of the impairment of the functionality of the visual system increases mediolateral sway, while impairment of the functionality of vestibular and proprioceptive systems increases anteroposterior sway [69]. Based on this review, it is unknown how these subgroups interact with each other or compensate for each other’s deficiency during the sensory integration process for balance control after physiotherapy compared to wait-list or placebo treatment. Because the unmentioned sway direction for balance assessment [20] and findings of the conflicting to limiting evidence for proprioception after physiotherapy compared to wait-list or placebo treatment prevent us from making direct conclusions about it. On the other hand, the studies included in this review consisted of people with neck pain and concurrent cervicogenic dizziness who had a wide range of ages (18 to 90 years), which may affect balance assessment since the visual and vestibular system function is altered with age. Visual information gradually decreases with age until middle ages, but increases again in older ages [70]. Contrary, vestibular information increases steadily up to a maximum until middle ages in order to compensate for visual deterioration, and then decreases again in older ages due to mostly correction of the visual system deterioration with glasses or surgery [70]. Therefore, it might be expected that balance impairment may be mainly reflected by increased mediolateral sway as a result of visual system deterioration in middle age, yet more research is needed to support this hypothesis and by increased anteroposterior sway due to vestibular and proprioceptive system dysfunction in older age, yet more research is needed to support this hypothesis. Yet, more research is needed to support this hypothesis.

Limited to conflicting evidence exists for the effectiveness of physiotherapy compared to wait-list or placebo treatment intermediate- and long-term or between different forms of physiotherapy in the short-, intermediate- and long-term. Therefore, these follow-up periods are unfit for conclusive judgments due to being represented by a single study or insufficient evidence. Thus, additional studies are still warranted.

Strengths and limitations

This systematic review was performed in accordance with PRISMA guidelines in order to ensure that all aspects of this systematic review are transparently, completely, and accurately reported, thus facilitating evidence-based decision-making To reduce the likelihood of any potential bias, study selection and quality rating of each study were blindly performed Additionally, by reviewing the evidence concerning a broad range of physiotherapy, rather than focusing on one specific type of intervention, it has been possible to highlight the emerging evidence concerning the beneficial effects of physiotherapy compared to wait-list or placebo treatment, or compared to another form of physiotherapy.

This systematic review has some limitations. A meta-analysis was not conducted due to concerns of heterogeneity between studies since most studies had relatively small sample sizes and variability in case definitions, and interventions. Although studies published in English and Dutch were included, some relevant studies could have been missed. The use of small sample sizes in some of the studies increases the risk of inadequate power to demonstrate a significant difference and make a stronger conclusion. There might be potential data extraction errors since single data extraction generates more errors than double data extraction. However, the available evidence suggests that the effect of data extraction error seems to be minor in systematic reviews of continuous outcomes [71].

For future research, the focus should be on high-quality randomized controlled trials with sufficient sample size to draw firm conclusions about the effectiveness of physiotherapy in intermediate- and long-term follow-up time frames.

Conclusion

Physiotherapy provides a greater improvement in CROM but provides similar effects on balance in the short-term compared to wait-list or placebo treatment with moderate quality of evidence.

Additionally, physiotherapy results in greater improvement in pain intensity in the short-term and intermediate-term, self perceived neck pain and disability, self-perceived handicap imposed by dizziness in the short-term compared to wait-list or placebo treatment based on MCIDs with limited evidence. There is no evidence for differences in pain-, dizziness-, tinnitus-, and psychological-related factors and objective functional status between physiotherapy and wait-list or placebo treatment or between different forms of physiotherapy in the intermediate- and long-term, or the differences between the groups have insufficient evidence.

Implications for clinical practice and research

Physiotherapy provides a greater improvement in some pain (pain intensity, self perceived neck pain and disability)- and dizziness-related factors (self-perceived handicap imposed by dizziness) and objective functional status (CROM) in the short-term compared to wait-list or placebo treatment in people with neck pain and concurrent cervicogenic dizziness. Further research would be needed to establish for efficiacy of physiotherapy in people with neck pain and concurrent cervicogenic tinnitus.

Supplementary Information

Supplementary Material 1.^{(30.8KB, docx)}

Supplementary Material 2.^{(72.5KB, docx)}

Supplementary Material 3.^{(32.3KB, docx)}

Authors’ contributions

1)Conception and design: Indra De Greef, Eveline Van Looveren, Kayleigh De Meulemeester 2)Acquisition of data and interpretation of data: Kübra Canlı, Indra De Greef 3)Drafting the article: Kübra Canlı 4)Revising the manuscript critically for important intellectual content: Kübra Canlı, Indra De Greef, Eveline Van Looveren, Barbara Cagnie, Mira Meeus, Kayleigh De Meulemeester 5)Final approval of the version to be published: Barbara Cagnie, Mira Meeus, Kayleigh De Meulemeester.

Funding

No funding was provided for this review from any source.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Kübra Canlı and Indra De Greef contributed equally to this work.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Material 1.^{(30.8KB, docx)}

Supplementary Material 2.^{(72.5KB, docx)}

Supplementary Material 3.^{(32.3KB, docx)}

Data Availability Statement

No datasets were generated or analysed during the current study.

[CR1] 1.Vingård E. Chapter 5.6: major public health problems - musculoskeletal disorders. Scand J Public Health Suppl. 2006;67:104–12. [DOI] [PubMed] [Google Scholar]

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[CR7] 7.Ren YF, Isberg A. Tinnitus in patients with temporomandibular joint internal derangement. Cranio. 1995;13(2):75–80. [DOI] [PubMed] [Google Scholar]

[CR8] 8.De Meulemeester K, Meeus M, De Pauw R, Cagnie B, Keppler H, Lenoir D. Suffering from chronic tinnitus, chronic neck pain, or both: does it impact the presence of signs and symptoms of central sensitization? PLoS One. 2023;18(8):e0290116. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR9] 9.Humphreys BK, Bolton J, Peterson C, Wood A. A cross-sectional study of the association between pain and disability in neck pain patients with dizziness of suspected cervical origin. J Whiplash Relat Disord. 2002;1(2):63–73. [Google Scholar]

[CR10] 10.Michiels S, De Hertogh W, Truijen S, Van de Heyning P. Cervical spine dysfunctions in patients with chronic subjective tinnitus. Otol Neurotol. 2015;36(4):741–5. [DOI] [PubMed] [Google Scholar]

[CR11] 11.Li Y, Yang L, Dai C, Peng B. Proprioceptive cervicogenic dizziness: a narrative review of pathogenesis, diagnosis, and treatment. J Clin Med. 2022;11(21):6293. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR12] 12.Kristjansson E, Treleaven J. Sensorimotor function and dizziness in neck pain: implications for assessment and management. J Orthop Sports Phys Ther. 2009;39(5):364–77. [DOI] [PubMed] [Google Scholar]

[CR13] 13.Oostendorp RA, Bakker I, Elvers H, Mikolajewska E, Michiels S, De Hertogh W, et al. Cervicogenic somatosensory tinnitus: an indication for manual therapy? Part 1: theoretical concept. Man Ther. 2016;23:120–3. [DOI] [PubMed] [Google Scholar]

[CR14] 14.Haider HF, Hoare DJ, Costa RFP, Potgieter I, Kikidis D, Lapira A, et al. Pathophysiology, diagnosis and treatment of somatosensory tinnitus: a scoping review. Front Neurosci. 2017;11:207. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR15] 15.Lee H, Hübscher M, Moseley GL, Kamper SJ, Traeger AC, Mansell G, et al. How does pain lead to disability? A systematic review and meta-analysis of mediation studies in people with back and neck pain. Pain. 2015;156(6):988–97. [DOI] [PubMed] [Google Scholar]

[CR16] 16.Pickar JG, Bolton PS. Spinal manipulative therapy and somatosensory activation. J Electromyogr Kinesiol. 2012;22(5):785–94. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR17] 17.Reid SA, Rivett DA, Katekar MG, Callister R. Comparison of mulligan sustained natural apophyseal glides and maitland mobilizations for treatment of cervicogenic dizziness: a randomized controlled trial. Phys Ther. 2014;94(4):466–76. [DOI] [PubMed] [Google Scholar]

[CR18] 18.Reid SA, Rivett DA, Katekar MG, Callister R. Sustained natural apophyseal glides (SNAGs) are an effective treatment for cervicogenic dizziness. Man Ther. 2008;13(4):357–66. [DOI] [PubMed] [Google Scholar]

[CR19] 19.Reid SA, Callister R, Snodgrass SJ, Katekar MG, Rivett DA. Manual therapy for cervicogenic dizziness: long-term outcomes of a randomised trial. Man Ther. 2015;20(1):148–56. [DOI] [PubMed] [Google Scholar]

[CR20] 20.Reid SA, Callister R, Katekar MG, Rivett DA. Effects of cervical spine manual therapy on range of motion, head repositioning, and balance in participants with cervicogenic dizziness: a randomized controlled trial. Arch Phys Med Rehabil. 2014;95(9):1603–12. [DOI] [PubMed] [Google Scholar]

[CR21] 21.Moustafa IM, Diab AA, Harrison DE. The effect of normalizing the sagittal cervical configuration on dizziness, neck pain, and cervicocephalic kinesthetic sensibility: a 1-year randomized controlled study. Eur J Phys Rehabil Med. 2017;53(1):57–71. [DOI] [PubMed] [Google Scholar]

[CR22] 22.Michiels S, de Van Heyning P, Truijen S, Hallemans A, De Hertogh W. Does multi-modal cervical physical therapy improve tinnitus in patients with cervicogenic somatic tinnitus? Man Ther. 2016;26:125–31. [DOI] [PubMed] [Google Scholar]

[CR23] 23.Michiels S, Naessens S, de Van Heyning P, Braem M, Visscher CM, Gilles A, et al. The effect of physical therapy treatment in patients with subjective tinnitus: a systematic review. Front Neurosci. 2016;10:545. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR24] 24.Micarelli A, Viziano A, Granito I, Carlino P, Micarelli RX, Augimeri I, et al. Postural and clinical outcomes of sustained natural apophyseal glides treatment in cervicogenic dizziness patients: a randomised controlled trial. Clin Rehabil. 2021;35(11):1566–76. [DOI] [PubMed] [Google Scholar]

[CR25] 25.Karlberg M, Magnusson M, Malmström EM, Melander A, Moritz U. Postural and symptomatic improvement after physiotherapy in patients with dizziness of suspected cervical origin. Arch Phys Med Rehabil. 1996;77(9):874–82. [DOI] [PubMed] [Google Scholar]

[CR26] 26.D’Sylva J, Miller J, Gross A, Burnie SJ, Goldsmith CH, Graham N, et al. Manual therapy with or without physical medicine modalities for neck pain: a systematic review. Man Ther. 2010;15(5):415–33. [DOI] [PubMed] [Google Scholar]

[CR27] 27.Carrasco-Uribarren A, Rodriguez-Sanz J, López-de-Celis C, Pérez-Guillen S, Tricás-Moreno JM, Cabanillas-Barea S. Short-term effects of the traction-manipulation protocol in dizziness intensity and disability in cervicogenic dizziness: a randomized controlled trial. Disabil Rehabil. 2022;44(14):3601–9. [DOI] [PubMed] [Google Scholar]

[CR28] 28.Carrasco-Uribarren A, Pardos-Aguilella P, Pérez-Guillén S, López-de-Celis C, Rodríguez-Sanz J, Cabanillas-Barea S. Combination of two manipulative techniques for the treatment of cervicogenic dizziness: a randomized controlled trial. Life. 2022;12(7):1023. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR29] 29.Aydin T, Dernek B, Sentürk Ege T, Karan A, Aksoy C. The effectiveness of dry needling and exercise therapy in patients with dizziness caused by cervical myofascial pain syndrome; prospective randomized clinical study. Pain Med. 2019;20(1):153–60. [DOI] [PubMed] [Google Scholar]

[CR30] 30.Atan T, Atan D, Özel S. Effectiveness of Kinesio taping in the treatment of somatosensory tinnitus: a randomized controlled trial. Complement Ther Clin Pract. 2020;39:101100. [DOI] [PubMed] [Google Scholar]

[CR31] 31.De Vestel C, Vereeck L, Reid SA, Van Rompaey V, Lemmens J, De Hertogh W. Systematic review and meta-analysis of the therapeutic management of patients with cervicogenic dizziness. J Man Manip Ther. 2022;30(5):273–83. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR32] 32.Lystad RP, Bell G, Bonnevie-Svendsen M, Carter CV. Manual therapy with and without vestibular rehabilitation for cervicogenic dizziness: a systematic review. Chiropr Man Therap. 2011;19(1):21. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR33] 33.Sharma P, Singh G, Kothiyal S, Goyal M. Effects of manual therapy in somatic tinnitus patients associated with cervicogenic and temporomandibular dysfunction domain: systematic review and meta analysis of randomised controlled trials. Indian J Otolaryngol Head Neck Surg. 2022;74(2):247–53. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR34] 34.Yaseen K, Hendrick P, Ismail A, Felemban M, Alshehri MA. The effectiveness of manual therapy in treating cervicogenic dizziness: a systematic review. J Phys Ther Sci. 2018;30(1):96–102. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR35] 35.Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Ann Intern Med. 2009;151(4):W65-94. [DOI] [PubMed] [Google Scholar]

[CR36] 36.Meeus M, Gebruers N: Health literacy: from reference to review; 2016.

[CR37] 37.http://www.ncbi.nlm.nih.gov/pubmed

[CR38] 38.www.embase.com

[CR39] 39.http://isiwebofknowledge.com

[CR40] 40.https://pedro.org.au

[CR41] 41.Stanley K. Design of randomized controlled trials. Circulation. 2007;115(9):1164–9. [DOI] [PubMed] [Google Scholar]

[CR42] 42.Michiels S, Cardon E, Gilles A, Goedhart H, Vesala M, Schlee W. Somatosensory tinnitus diagnosis: diagnostic value of existing criteria. Ear Hear. 2022;43(1):143–9. [DOI] [PubMed] [Google Scholar]

[CR43] 43.Brandt T, Bronstein AM. Cervical vertigo. J Neurol Neurosurg Psychiatry. 2001;71(1):8–12. [DOI] [PMC free article] [PubMed] [Google Scholar]

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PERMALINK

The effects of physiotherapy on neck pain with associated symptoms, including cervicogenic dizziness and tinnitus: a systematic review

Kübra Canlı

Indra De Greef

Eveline Van Looveren

Mira Meeus

Barbara Cagnie

Kayleigh De Meulemeester

Abstract

Objective

Methods

Results

Conclusion

Trial registration

Supplementary Information

Introductıon

Materıals and methods

Protocol registration

Research question

Information sources and search strategy

Eligibility criteria and study selection

Inclusion criteria

Patients

Intervention

Exclusion criteria

Table 1.

Outcome measures

Data extraction

Risk of bias

Data synthesis

Results

Study selection

Fig. 1.

Study characteristics

Outcome measures

Interventions

Risk of bias

Table 2.

Level of evidence

Table 3.

Results of individual studies

Adverse events

Discussion

Strengths and limitations

Conclusion

Implications for clinical practice and research

Supplementary Information

Authors’ contributions

Funding

Data availability

Declarations

Ethics approval and consent to participate

Competing interests

Footnotes

References

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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