When the Neck Wavers, the World Turns

1. Abstract

When neck pain and dizziness occur together, whether the two symptoms share a single cause must be judged separately. Craniocervical instability (CCI) is a problem of structural stability; cervicogenic dizziness is a clinical concept whose mechanism and diagnostic criteria remain contested; and cervical hyperlordosis is a radiographic finding that describes alignment. This paper does not treat the three as a single disease continuum. It organizes them as three domains for evaluating neck-related dizziness—structure, sensorimotor function, and alignment— and separates the evidence and the limits of each. The biomedical literature shows, at once, the low sensitivity of ligament tests (Hutting 2013), the normal variance of radiographic indices (Gordillo 2025), the discriminative value of sensorimotor tests (L'Heureux-Lebeau 2014), the partial effect of manual therapy (Reid 2015), and the skeptical position of the Bárány Society (Seemungal 2022). The classical Korean medical sources recorded the same phenomenon in two lineages. The passage in the Lingshu chapter "Da huo lun" (大惑論)—"when a pathogen strikes the nape (邪中於項), the brain turns and the eyes are dizzied"—belongs to the wind-entry (風入) lineage, while the "Wei qi" (衛氣) chapter's "when the upper part is deficient, there is dizziness (上虛則眩)" belongs to the deficiency (虛) lineage. The Dongui Bogam (東醫寶鑑) places the two sentences side by side and annotates them, respectively, "this speaks of dizziness from wind entering" and "this speaks of dizziness from deficiency." Three conclusions follow. First, before the neck is treated by hand, dangerous causes (vascular, central) and common vestibular causes (vestibular migraine, BPPV) must be considered, and screening for upper cervical instability must be performed with the understanding that a negative result does not guarantee safety. Second, the modern evidence for Korean medical treatment differs by domain: acupuncture has low-to-very-low-quality evidence in the sensorimotor domain, no direct evidence for Chuna manual therapy or deficiency-pattern formulas in cervicogenic dizziness was identified in this search, and forceful manipulation of a region suspected of structural instability is to be avoided. Third, the two Lingshu sentences did not anticipate modern tests; they left a question—to examine the nape, the eyes, and the body's deficiency or excess together—and that question overlaps with today's order of differential diagnosis.

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2. Context of the Question

Some patients report dizziness when turning the head, a stiff nape after prolonged sitting, and difficulty holding the head up. Many arrive at a Korean medicine clinic after otolaryngology and neurology have found "nothing abnormal." Yet a single unremarkable work-up does not establish the neck as the cause. A neck problem may contribute to dizziness; the neck may have stiffened because the patient moves the head less to avoid dizziness; or the two symptoms may overlap from independent causes.

This distinction must begin with the current official position of vestibular medicine. In its 2022 position paper, the Bárány Society Classification Oversight Committee judged that "the evidence supporting a mechanistic link between an illusory sensation of self-motion and neck pathology and/or symptoms of neck pain is lacking," and stated that the commonest cause of combined neck pain and vestibular symptoms is migraine, including vestibular migraine. The committee also noted that, because head movement aggravates symptoms in almost any vestibular condition, the increased neck muscle tension commonly seen in vestibular patients may be both cause and effect of reduced head movement. It accepted that further research is required to determine whether the rare cases in which neck muscle spasm is associated with a vague sense of spatial disorientation are linked to impaired neck proprioception, and it refrained from proposing preliminary diagnostic criteria for clinical use outside a research setting. — Seemungal et al., 2022, Journal of Vestibular Research DOI

Orthopaedic medicine textbooks had earlier described it as "of extreme importance" to differentiate dizzy patients into three groups: "the patient who shows a contraindication for any type of cervical treatment, when the problem lies within the vertebrobasilar system"; "the patient whose vertigo has nothing to do with the neck, when the vestibular system is affected"; and "the patient in whom the vertigo is cervicogenic and can be treated as such, when the proprioceptive system is disturbed." The same text records that "others doubt the existence of cervical vertigo as an independent entity and strongly emphasize the need to exclude neurological, vestibular and psychosomatic disorders first." — Ombregt L. A System of Orthopaedic Medicine, 3rd ed. Elsevier; 2013. Online chapter "Headache and vertigo of cervical origin," e32, e36

Accordingly, this paper uses "cervicogenic dizziness" only as the term employed by the studies cited, and in general discussion also uses "neck-related dizziness," which presupposes less about causation.

The classical sources recorded the nape and dizziness in two strands. The Lingshu "Da huo lun" describes the route by which a pathogen enters at the nape and reaches the brain and the eyes; the "Wei qi" chapter describes how symptoms differ according to deficiency or excess above and below. The Dongui Bogam set the two side by side within a single section on dizziness (眩暈) and annotated one as wind entry and the other as deficiency. What the clinician gains from this study is not "which treatment is better" but what must be checked before the neck of a dizzy patient is touched, in which of the three domains this patient's problem lies, and where the line falls between the domains in which Korean medical treatment has evidence and those in which it should be avoided.

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3. What the Literature Says

1. Structural stability: between suspicion and confirmation

Craniocervical instability is a state in which stability between the skull and the upper cervical spine is compromised by damage to, or laxity of, the transverse ligament, the alar ligaments, or the atlanto-occipital membranes. Its causes are diverse: trauma, rheumatoid arthritis, long-term corticosteroid use, congenital malformation, Down syndrome, osteoporosis, and connective tissue disorders such as Ehlers-Danlos syndrome (EDS). The standard textbook of orthopaedic physical assessment lists the signs of instability as "severe muscle spasm, patient does not want to move head (especially into flexion), lump in throat, lip or facial paresthesia, severe headache, dizziness, nausea, vomiting, soft end feel, nystagmus, pupil changes," and states plainly that "if instability is present, mobilization and/or manipulation should not be performed." — Magee DJ, Manske RC. Orthopedic Physical Assessment, 7th ed. Elsevier; 2021. ch. 3, p. 212

The tests described include the Sharp-Purser test, the lateral flexion and rotational alar ligament stress tests, the anterior shear test, the posterior atlanto-occipital membrane test, and the Aspinall transverse ligament test. The Sharp-Purser test "should be performed with extreme caution"; in the rotational alar ligament stress test, if more than 20–30° of rotation is possible with C2 stabilized and without C2 moving, injury to the contralateral alar ligament is suggested. — Ibid., pp. 212–214

The problem is accuracy. In a systematic review of five studies, the specificity of seven tests was sufficient, but sensitivity varied, the confidence intervals of the likelihood ratios were in most cases wide, and none of the studies evaluated the tests in patients receiving primary care. The membrane tests had the best diagnostic accuracy, but their applicability in primary care remained unconfirmed. — Hutting et al., 2013, Physical Therapy DOI

In short, a single negative test cannot exclude instability or guarantee the safety of forceful cervical manipulation.

Radiographic measurements must likewise be read together with the conditions of imaging. The atlantodental interval (ADI) is normally less than 3 mm in adults and less than 5 mm in children; textbooks illustrate a case widened to 5 mm in rheumatoid arthritis. — Yochum TR, Rowe LJ (Korean edition ed. Nam Hang-woo). Imaging Diagnosis of Spinal Disorders, pp. 18–22; DeLee JC, Drez D. Orthopaedic Sports Medicine, 2nd ed. Saunders; 2003. p. 823

In a study of 72 healthy individuals with cervical imaging (mean age 64), all measurements except the ADI and the basion-axial interval—the clivo-axial angle, the basion-dens interval, the Grabb-Oakes measurement, and the distances from hard palate to C1 and C2—differed significantly between flexion and extension, while the clivo-axial angle and the hard palate distances showed the lowest coefficients of variation across imaging modalities. This is evidence of the risk in judging CCI from a single static image; it is not evidence that dynamic imaging should be obtained in every dizzy patient. — Gordillo et al., 2025 (online 2024), Clinical Spine Surgery DOI

Nor is there an upper limit for "minor instability." Citing the observation that 10% of college freshman football players (7 of 75) demonstrated abnormal motion, the textbook concedes that "there are no data available … that allow reliable standards" for what the upper limits of minor instability are. — DeLee & Drez, ibid., p. 823

Surgical data come from a still narrower population. Fifty-three EDS patients with severe headache and neck pain, lower cranial nerve deficits, cervical medullary syndrome, myelopathy, and radiological findings of CCI showed, 5–28 months (mean 15.1) after occipito-cervical fusion, significant improvement in headache and neck pain (p<0.001), nausea and syncope (p<0.001), and vertigo, dizziness, speech difficulty, concentration, arm weakness, and fatigue (p=0.001). — Henderson et al., 2024, Neurosurgical Review DOI

The study, however, was retrospective and uncontrolled, and a critique in the same journal pointed to the sample size, the absence of a control group, and the lack of long-term follow-up. — Mughal et al., 2024, Neurosurgical Review DOI

Two things are to be taken from these data: dizziness is on the symptom list of CCI, and surgical outcomes in EDS cannot be transferred to the general neck-pain patient.

2. Sensorimotor function: what a measurable difference means

The physiological fact that positional information from the neck participates in locating the head relative to the body must be distinguished from the judgment that a particular patient's dizziness arises from a disturbance of that information. The orthopaedic medicine textbook summarizes cervical proprioceptive disturbance as follows: "elements that point towards a vestibular disorder (turning sensations, motion sickness) are absent; the patient does not mention one of the 5 D symptoms (dizziness, dysarthria, dysphagia, diplopia, drop attacks); there is no nystagmus; the neck movements are positive in that they indicate a cervical disorder—pain, stiffness, possibly diminished range of motion, articular pattern." As an aid to separating vestibular from cervical origin, it presents the turning/stop-turning test of Oostendorp, in which the patient is rotated ten times on a revolving stool with eyes closed and then stopped. — Ombregt, ibid., e35–e36

This test is a textbook description, not a standard procedure validated by diagnostic accuracy studies. The quantitative evidence lies in the following studies. In a comparison of 25 patients classified as having cervicogenic dizziness and 25 with BPPV, the cervicogenic group was more likely to describe a sensation of drunkenness or lightheadedness, to have pain provoked on physical examination of the upper cervical vertebrae, to show a cervical joint position error (JPE) of 4.5°, and to exhibit nystagmus above 2°/s on the cervical rotation test (Youden index 0.60). — L'Heureux-Lebeau et al., 2014, Otology & Neurotology DOI

These values must be read within the conditions of that comparison with BPPV; they are not confirmatory criteria applicable to all dizziness, including vestibular migraine and central causes. Moreover, the textbook statement that "there is no nystagmus" (spontaneous) and the research finding of test-provoked nystagmus operate on different levels, so the presence or absence of nystagmus alone cannot decide whether the origin is vestibular.

In a study comparing 20 subjects each with persistent whiplash, acoustic neuroma, and healthy controls, the smooth pursuit neck torsion (SPNT) test and postural stability distinguished the whiplash group from the vestibular group, supporting the SPNT as a test of cervical afferent dysfunction. — Treleaven et al., 2008, Archives of Physical Medicine and Rehabilitation DOI

A meta-analysis of 34 studies reported poorer joint position sense, oculomotor function, and wider postural sway in individuals with neck pain than in healthy controls, with the size of the difference influenced by pain intensity and the presence of dizziness. — Särkilahti et al., 2024, Scientific Reports DOI

The myofascial pain literature locates this dizziness at the level of individual muscles. Trigger points in the clavicular division of the sternocleidomastoid produce "postural dizziness (a disagreeable movement or sensation within the head)," and exaggerated postural responses—"when looking up, they feel as if they will pitch over backwards, and when glancing down, they tend to fall forward"—together with nausea are common. The authors distinguish dizziness from vertigo, note that vestibular disease is identified by nystagmus and vestibular function tests, and list non-vestibular causes to be excluded, including internal carotid stenosis, hypertension, and orthostatic hypotension. — Simons DG, Travell JG, Simons LS. Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol. 1, 2nd ed. Williams & Wilkins; 1999. ch. 7, pp. 308–319

Trigger points in the suboccipital muscles are activated by "a forward-head posture with a posteriorly rotated occiput, by abuse of the checkrein function during sustained head flexion, by abuse of the extension function during sustained upward head tilt." — Ibid., ch. 17, p. 472

This is the observation that links the sensorimotor domain to the alignment domain.

3. Alignment: between angle and symptom

Cervical lordosis must be read together with age, measurement method, and the shape of the adjacent spine. In 307 asymptomatic young Chinese adults (18–30 years), C2–C7 lordosis averaged 17.11° ± 6.31° and was predicted by the T1 slope (25.84° ± 5.36°), the thoracic inlet angle, and the C2–C7 sagittal vertical axis (CL = 0.762 × T1S − 0.392 × SVA + 0.25 × TIA − 13.795). — Zhu et al., 2020, Journal of Orthopaedic Surgery and Research DOI

This value is a descriptive statistic of a particular sample, not a diagnostic threshold for all adults. What the regression does show is clear: cervical lordosis is not a value determined within the neck alone; it is related to adjacent alignment parameters such as the T1 slope.

The textbook of postural classification describes the "kyphosis-lordosis posture" as "head: forward; cervical spine: hyperextended; scapulae: abducted; thoracic spine: increased flexion (kyphosis)," and notes that in this posture "weakness usually exists in the anterior neck and upper back muscles." — Kendall FP, McCreary EK. Muscles: Testing and Function, 3rd ed. Williams & Wilkins; 1983. Posture chapter, pp. 281–282

In radiographic measurement, Ruth Jackson's stress lines take as their reference the intersection of the posterior lines of C2 and C7 at C5/6 in flexion and at C4/5 in extension, and explain that "muscle spasm, joint fixation, and disc degeneration may alter the stress point." — Yochum & Rowe (Nam ed.), ibid., pp. 22–23

A distinction is needed here. A large overall C2–C7 lordosis and hyperextension of the upper cervical spine (C0–C2) differ from the outset in what is measured. What is commonly seen in forward-head posture is the latter, and if the posture of the upper cervical spine is described by a single lower cervical angle, different shapes come to be called by the same name, "hyperlordosis." And the chain "alignment change → ligament load → dizziness" is not a conclusion that the studies above confirmed. Alignment is a datum that supplements sensorimotor assessment; there is no basis for inferring CCI because an angle is large, or for claiming that correcting the angle prevents the recurrence of dizziness.

4. What treatment studies have shown and not shown

In a trial that randomized 86 patients with chronic cervicogenic dizziness (mean age 62) to sustained natural apophyseal glides (SNAGs) with self-SNAGs, passive joint mobilization with range-of-motion exercise, or placebo, both manual therapy groups at 12 months had lower dizziness frequency than placebo (SNAG −0.7, 95% CI −1.3 to −0.2; PJM −0.7, −1.2 to −0.1) and lower Dizziness Handicap Inventory scores (SNAG −8.9, 95% CI −16.3 to −1.6; PJM −13.6, −20.8 to −6.4). There were, however, no between-group differences in dizziness intensity, pain intensity, or head repositioning accuracy (HRA). No adverse effects were reported. — Reid et al., 2015 (online 2014), Manual Therapy DOI

Because exercise accompanied the intervention, the effect cannot easily be attributed to the manual technique alone, and the absence of adverse effects in this sample does not establish the safety of all cervical manual therapy.

A systematic review of 13 studies (785 patients) of neck pain with concurrent dizziness or tinnitus found 10 at high risk of bias; Mulligan mobilization showed an advantage in range of motion but no difference from placebo in short-term balance, and the evidence on pain intensity and dizziness handicap was conflicting. — Canlı et al., 2026, BMC Musculoskeletal Disorders DOI

Sensorimotor rehabilitation must be read according to its population. In a 2×2 factorial trial of 152 patients with neck pain, the primary outcomes were postural sway and joint position error; dizziness was a secondary outcome. All four groups improved in the short and long term, and the group that added joint-position-sense and oculomotor training plus balance training to local treatment improved most in balance under neck torsion and in joint position sense, and was superior in maintaining gains in pain and disability at 6 and 12 months. — Sremakaew et al., 2023 (online 2022), Musculoskeletal Science and Practice DOI

The evidence for deep cervical flexor training is collected in the rehabilitation textbooks. The craniocervical flexion (CCF) test inflates a pressure sensor to 20 mmHg and asks the patient to hold a nodding motion for 10 seconds at each of five increments from 22 to 30 mmHg; young and middle-aged adults should be able to reach 26–30 mmHg without recruiting the superficial muscles. — Magee & Manske, ibid., p. 199

Jull and colleagues reported test–retest reliability of this test in 50 asymptomatic subjects as ICC 0.81 for the activation score and 0.93 for the performance index, and in a separate study a pressure-device craniocervical flexion exercise improved repositioning acuity to nearly the same extent as a proprioceptive training regimen (Jull 2007b). — Kisner C, Colby LA. Therapeutic Exercise, 7th ed. F.A. Davis; 2018. p. 515; Brotzman SB, Manske RC. Clinical Orthopaedic Rehabilitation, 3rd ed. Elsevier; 2011. p. 460

Trial results for SNAGs or a particular joint mobilization are not direct evidence for Chuna manual therapy (推拿, chuna—the Korean system of manual spinal and joint treatment) as a whole. How closely the technique, the region treated, patient selection, and the accompanying exercise correspond must be examined.

5. The two Lingshu sentences ask different questions

The classical sentence that joins the nape and dizziness in a single pathway is in the Lingshu "Da huo lun," and the Dongui Bogam reproduced it verbatim.

藏府筋骨血氣之精, 與脉幷爲目系, 上屬於腦, 後出於項中. 故邪中於項, 因逢其身之虛, 其入深, 則隨眼系以入於腦, 入於腦則腦轉, 腦轉則引目系急, 目系急則目眩以轉矣. 此言風入而眩暈. 《靈樞》 The essence of the viscera, sinews, bones, blood, and qi joins with the vessels to form the eye connector (目系), which ascends to attach to the brain and emerges behind at the center of the nape. Therefore, when a pathogen strikes the nape and, meeting the body in a state of deficiency, enters deeply, it follows the eye connector into the brain; when it enters the brain, the brain turns; when the brain turns, it pulls the eye connector taut; when the eye connector is taut, the eyes are dizzied and turn. This speaks of dizziness from wind entering. (Lingshu) — Dongui Bogam (東醫寶鑑), Oehyeong pyeon, vol. 1, Head, "Dizziness," quoting Lingshu "Da huo lun" (https://mediclassics.kr/books/8/volume/5#content_55; original in Lingshu: https://mediclassics.kr/books/184/volume/12#content_19)

In this sentence there is a way of thinking that understands nape, brain, and eyes within a single pathway, and it places the intrusion of a pathogen (邪) and the body's vulnerability (身之虛) together. The Dongui Bogam classified it under the wind-entry (風入) lineage. The eye connector cannot be translated one-to-one into a particular nerve, "the brain turns" (腦轉) into vestibular nuclear dysfunction, or "the eye connector taut" (目系急) into an abnormal oculomotor test. Yet the fact that the order of observation—"a pathology beginning at the nape passes through the brain and shows itself in the movement of the eyes"—is arranged in the same direction as the modern sensorimotor model of upper cervical afferent input → central integration → oculomotor and postural disturbance is a reasonable starting point for comparison.

The deficiency (虛) lineage comes from the "Wei qi" chapter.

凡候此者, 下虛則厥, 下盛則熱, 上虛則眩, 上盛則熱痛. In all cases where these [the roots and branches of the twelve channels] are examined: deficiency below produces reversal cold; excess below produces heat; deficiency above produces dizziness; excess above produces heat and pain. — Huangdi Neijing Lingshu (黃帝內經靈樞), vol. 8, "Wei qi," ch. 52 (https://mediclassics.kr/books/184/volume/8#content_29)

上虛則眩. 又曰, 上氣不足, 目爲之眩. 此言虛而眩暈. When the upper part is deficient, there is dizziness. It is also said: when the upper qi is insufficient, the eyes are dizzied. This speaks of dizziness from deficiency. — Dongui Bogam, Oehyeong pyeon, vol. 1, Head, "Dizziness" (https://mediclassics.kr/books/8/volume/5#content_54)

What matters is that the Dongui Bogam set "this speaks of dizziness from deficiency" and "this speaks of dizziness from wind entering" side by side within a single section. The classical account of dizziness is not reducible to deficiency alone; the same section also enumerates dizziness according to wind, heat, phlegm, qi, and dampness. Lou Ying's (樓英) Yixue Gangmu (醫學綱目) likewise places the same "Da huo lun" passage under the heading "dizziness from externally contracted wind pathogen" (外感風邪眩) in the section on dizziness within the Liver and Gallbladder division, and places the "Wei qi" sentence "deficiency above produces dizziness" under a separate heading, "dizziness from deficiency above" (上虛眩), thereby separating the two lineages at the level of the classificatory scheme itself. — Yixue Gangmu (醫學綱目), vol. 11, Liver and Gallbladder, Dizziness, "Externally contracted wind pathogen dizziness" (https://mediclassics.kr/books/132/volume/11#content_31); "Deficiency above dizziness" (https://mediclassics.kr/books/132/volume/11#content_42)

Zhang Jingyue (張景岳) was the physician who pressed the deficiency lineage most forcefully.

凡病中眩運, 多因淸陽不升, 上虛而然. 如丹溪云 "無痰不作運", 殊非眞確之論, 但當兼形氣ㆍ分久暫以察之. 觀《內經》曰: "上虛則眩, 上盛則熱痛", 其義可知. 至於頭重, 尤屬上虛. 《經》曰: "上氣不足, 腦爲之不滿, 頭爲之苦傾", 此之謂也. Dizziness in the course of illness is mostly because clear yang fails to ascend and the upper part is deficient. Danxi's saying, "without phlegm there is no dizziness," is by no means an accurate doctrine; one must examine form and qi together and distinguish the chronic from the transient. Consider the Neijing: "deficiency above produces dizziness; excess above produces heat and pain"—the meaning is clear. As for heaviness of the head, it belongs all the more to deficiency above. The Classic says: "when the upper qi is insufficient, the brain is not filled and the head suffers from tilting"—this is what is meant. — Jingyue Quanshu (景岳全書), Chuanzhong lu, "Ten Questions," Third Question: Head and Body (https://mediclassics.kr/books/139/volume/1#content_113)

"The head suffers from tilting" (頭爲之苦傾) overlaps in expression with the modern patient's complaint that the head is heavy and hard to hold up. To specify this "deficiency" as deep cervical flexor weakness or ligamentous laxity, however, is a later interpretation; the source does not point to tissue or mechanism. Jingyue's view is the argument of one physician, not a consensus of Korean medicine as a whole that all dizziness is deficiency.

The Shanghan lun (傷寒論) lineage binds nape stiffness and dizziness into a single syndrome while speaking of both deficiency and wind.

太陽與少陽併病, 頭項強痛, 或眩冒, 時如結胸, 心下痞堅者, 不可發其汗. When Taiyang and Shaoyang are diseased together, with stiffness and pain of the head and nape, sometimes dizziness and clouding, at times resembling chest binding, with hardness and fullness below the heart, sweating must not be induced. — Xinkan Wangshi Maijing (新刊王氏脉經), vol. 7, "Patterns in which sweating must not be induced," ch. 1 (https://mediclassics.kr/books/192/volume/7#content_31)

"二陽倂病, 頭項强痛, 或眩運眩冒者", 以少陽與太陽倂病, 故眩者責其虛也. ... 故針經有曰, "上虛則眩, 下虛則厥". 眩雖爲虛, 而風家亦有眩者, 蓋風主運動故爾. "When the two yang are diseased together, with stiffness and pain of the head and nape, sometimes dizziness and clouding"—this is Shaoyang diseased together with Taiyang, so the dizziness is attributed to deficiency. Hence the Needle Classic says, "deficiency above produces dizziness; deficiency below produces reversal." Although dizziness is a matter of deficiency, those with wind also have dizziness, because wind governs movement. — Shanghan Mingli lun (傷寒明理論), vol. 1, "Head dizziness," ch. 13 (https://mediclassics.kr/books/198/volume/1#content_71)

"The dizziness is attributed to deficiency" is followed immediately by "those with wind also have dizziness." The prohibition on inducing sweat is a clause about the sweating method of treatment; it cannot be translated into a contraindication for modern traction or high-velocity manipulation.

The record of acupuncture is in the Qianjin fang (千金方).

邪在腎, 則骨痛陰痺. 陰痺者, 撫之而不得, 腹脹腰痛, 大便難, 肩背頸項強痛, 時眩. 取之涌泉崑崙, 視有血者, 盡取之. When the pathogen is in the kidney, there is bone pain and yin impediment. In yin impediment, pressing does not locate it; there is abdominal distension and lumbar pain, difficult stools, stiffness and pain of the shoulders, back, neck, and nape, and dizziness from time to time. Treat it at Yongquan and Kunlun, and where blood is seen, drain it fully. — Beiji Qianjin Yaofang (備急千金要方), vol. 19, "Discourse on the kidney pulse," ch. 1 (https://mediclassics.kr/books/108/volume/22#content_25)

"Stiffness and pain of the shoulders, back, neck, and nape, and dizziness from time to time" is a record of the co-occurrence of neck-shoulder stiffness and intermittent dizziness, and the choice of points on the foot (Yongquan 涌泉, Kunlun 崑崙) is a historical example of distal point selection. To say that this embodies a mechanism of raising yang or the same principle as modern sensorimotor rehabilitation is interpretation, not the statement of the source.

The Hyangyak Jipseongbang (鄕藥集成方) left a principle of differentiation.

眩暈之證, 發於卒然之間, 眼目昏花, 如屋旋轉, 起則眩倒. ... 皆能令人一時眩暈, 目暗口噤, 頭痛項強. 臨病之際, 宜詳以脈證辨之. The pattern of dizziness arises suddenly; the eyes blur, the room seems to spin, and on standing one falls dizzily. … All these can cause momentary dizziness, darkened vision, clenched jaw, headache, and stiffness of the nape. When facing the illness, one must differentiate carefully by pulse and symptoms. — Hyangyak Jipseongbang, vol. 13, "Dizziness," quoting Yifang Dacheng (https://mediclassics.kr/books/93/volume/13#content_258)

"When facing the illness, one must differentiate carefully by pulse and symptoms" stands in the same place as the differentiation demanded by the Bárány position paper and the orthopaedic textbooks.

6. Modern evidence for Korean medical treatment

In a meta-analysis of 10 RCTs (914 participants) of acupuncture for cervical vertigo, acupuncture was superior to conventional medication in effectiveness rate, improvement of vertigo, and mean blood flow velocity of the vertebrobasilar artery, but the GRADE quality of evidence was very low to low and long-term safety remained uncertain. — Hou et al., 2017, Evidence-Based Complementary and Alternative Medicine DOI

No RCT of Chuna manual therapy for cervicogenic dizziness was identified within the scope of this search (PubMed and the author's textbook library). Nor do the classical indications of formulas such as Bojungikgi-tang (補中益氣湯) or Obok-eum (五福飮) by themselves demonstrate efficacy in modern cervicogenic dizziness.

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4. Cross-Reading

The three evaluation domains and the correspondence of the two medicines

Comparable perspectives

The perspectives that can be compared across the two medicines are narrowed to two. First, nape and dizziness are examined within a single pathway: the "Da huo lun" sentence 邪中於項 and the modern cervical afferent model share an order of observation. Second, dizziness involves both deficiency (虛) and pathogen (邪): the "Da huo lun" phrase 因逢其身之虛 and the "Wei qi" sentence 上虛則眩 set the body's vulnerability and the intrusion of a pathogen side by side. To set this against the modern findings of deep cervical flexor weakness and sensorimotor differences that scale with pain intensity, under the figure "a load laid upon a state of insufficiency," is the author's interpretation, and rendering 邪 as external load is likewise not the statement of the source but a translation for the sake of comparison. The two are not the same mechanism spoken in the same language; they form the hypothesis that records of the same phenomenon observed by different methods point in the same direction.

Points of conflict

The conflict arises in the structural domain. The classical "deficiency" is a concept of qi; the "deficiency" of true CCI is a physical deficit of ligament, which no formula replenishes. The orthopaedic medicine textbook classifies upper cervical ligamentous laxity due to rheumatoid arthritis as an absolute contraindication to manipulation and notes that "the typical soggy end-feel puts the examiner on his/her guard." — Ombregt, ibid., ch. 11, pp. 186–187

The reliability of the safety tests themselves is also disputed. Although routine vertebral artery testing before manipulation has become widely accepted, "studies have shown a high likelihood of obtaining false negative results, suggesting that the validity of the test is poor," and it has even been argued that "the sustained posture required for the test exposes the patient to greater risk than a quick, high-velocity manipulation." — Ombregt, ibid., ch. 11, pp. 183–184

The classical sources are silent on this dilemma. What they warned against was the misuse of sweating (a draining method), not the existence of a ligament deficit. In Korean medical practice, therefore, the classical judgment of deficiency or excess cannot replace modern risk assessment and must come after it.

Integrative implication: an order of clinical judgment

The following is a direction for evaluation constructed from the literature, not a validated diagnostic algorithm.

Step 1: establish onset, duration, provoking circumstances, and accompanying symptoms. Sudden and severe headache or neck pain, new neurological deficit, loss of consciousness, and marked gait disturbance are findings that require urgent evaluation before any functional treatment of the neck. Vascular risk is assessed chiefly by history and clinical judgment rather than by a single provocation test.

Step 2: consider the common vestibular causes (vestibular migraine, BPPV) and the systemic causes that need to be excluded. The presence of neck pain, changes on cervical imaging, and a normal result on other tests each fail, on their own, to establish a cervical cause.

Step 3: where a history of trauma, rheumatoid disease, or connective tissue disorder together with neurological findings suggests structural instability, refer for specialist evaluation. Perform the ligament tests, but do not use a negative result as a license for the next intervention.

Step 4: once dangerous causes have been evaluated, examine the temporal relation between neck pain and dizziness, mobility, sensorimotor function (JPE, SPNT, and the like), and the demands of daily life. Alignment supplements this evaluation.

Step 5: treat the sensorimotor domain (acupuncture, soft-tissue Chuna, SNAG-type techniques) and the alignment domain (thoracic mobilization, deep cervical flexors, posture) together; prescribe medication according to the pattern of deficiency or excess, on the premise that the formula itself carries no evidence for dizziness. Record the treatment response separately for dizziness intensity and frequency, daily function, and neck pain, and revisit the initial hypothesis if there is no improvement or the presentation changes.

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5. What Remains Unknown

This paper is not a systematic review but a narrative comparison of selected clinical literature and classical texts. It does not guarantee the comprehensiveness or reproducibility of the search and presents no new patient data. The classical Chinese sources were checked against individual pages of the MEDICLASSICS database, but no collation of variant characters or editions was undertaken. Textbook citations specify edition and page; the edition of the Korean translation of Imaging Diagnosis of Spinal Disorders and the edition of Kendall's posture chapter (judged to be the 3rd) remain to be checked against the originals.

First, the boundary between the structural and sensorimotor domains is blurred. Ligament tests have low sensitivity, radiographic indices vary between flexion and extension even in healthy individuals, and no upper limit for "minor instability" has been set.

Second, the diagnostic status of cervicogenic dizziness itself is undetermined. The Bárány Society has withheld preliminary clinical criteria. The JPE and SPNT studies cited here may have drawn on samples in which vestibular migraine was not adequately excluded.

Third, causation between alignment and dizziness has not been tested. The correlation between T1 slope and cervical lordosis is established, but the pathway by which upper cervical hyperextension causes dizziness through proprioceptive disturbance is this paper's hypothesis, not a research conclusion.

Fourth, the evidence for Korean medical treatment must be stated domain by domain. Acupuncture is GRADE very low to low; no RCT of Chuna and no clinical evidence for deficiency-pattern formulas in dizziness were identified in this search.

Fifth, to equate the classical "deficiency" with modern "weakness" is interpretation. The observation that the two concepts converge on the same treatment principle is this paper's thesis, not a demonstration.

Further research questions:

1. Does the relation between cervical sensorimotor abnormality and dizziness hold after vestibular migraine and BPPV have been evaluated?
2. When upper cervical posture (C0–C2) and C2–C7 lordosis are measured separately, which index relates to JPE and CCF performance?
3. Does the added effect of joint-position-sense, oculomotor, and balance training extend beyond improvement in neck pain to clinically important change in dizziness?
4. How does the 12-month change in DHI in a group combining soft-tissue Chuna with deep cervical flexor training differ from SNAGs alone?
5. Are Korean medical deficiency–excess pattern identification and CCF/JPE performance actually related, and if this relation is to be studied, how are the definition of the pattern and inter-rater agreement to be secured first?

The point of rereading the Lingshu sentences today is not to find modern test names within them. It is to put again, to the patient before us, the question that once examined the nape, the eyes, and the body's vulnerability together. To look at the neck and dizziness together, while not settling their relation too early, is both the starting point and the conclusion of this paper.

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References — Source Cards

Source 1 [KM]

• Source: Huangdi Neijing Lingshu (黃帝內經靈樞), vol. 8, "Wei qi" (衛氣), ch. 52
• Author/Era: Anonymous, Warring States–Han
• MEDICLASSICS: https://mediclassics.kr/books/184/volume/8#content_29 ("Da huo lun": https://mediclassics.kr/books/184/volume/12#content_19)
• Key point: "上虛則眩, 上盛則熱痛"—the context of the roots and branches of the twelve channels and of deficiency and excess above and below.

Source 2 [KM]

• Source: Dongui Bogam (東醫寶鑑), Oehyeong pyeon, vol. 1, Head, "Dizziness" (眩暈)
• Author/Era: Heo Jun, 1613
• MEDICLASSICS: https://mediclassics.kr/books/8/volume/5#content_54 (此言虛而眩暈), https://mediclassics.kr/books/8/volume/5#content_55 (此言風入而眩暈)
• Key point: Quotes the "Da huo lun" passage 邪中於項 with "this speaks of dizziness from wind entering"; "上虛則眩 … this speaks of dizziness from deficiency"—the two lineages placed side by side.

Source 3 [KM]

• Source: Jingyue Quanshu (景岳全書), Chuanzhong lu, "Ten Questions," Third Question: Head and Body
• Author/Era: Zhang Jiebin, 1624
• MEDICLASSICS: https://mediclassics.kr/books/139/volume/1#content_113 (Third Question); https://mediclassics.kr/books/139/volume/11#content_33 (Non-wind); https://mediclassics.kr/books/139/volume/17#content_217 (Dizziness, classical passages)
• Key point: Clear yang failing to ascend and deficiency above; rebuttal of Danxi's "without phlegm no dizziness"; "the head suffers from tilting."

Source 4 [KM]

• Source: Xinkan Wangshi Maijing (新刊王氏脉經), vol. 7, "Patterns in which sweating must not be induced," ch. 1; Shanghan Mingli lun (傷寒明理論), vol. 1, "Head dizziness," ch. 13
• Author/Era: Wang Shuhe, 3rd century; Cheng Wuji, 1142
• MEDICLASSICS: https://mediclassics.kr/books/192/volume/7#content_31 (Maijing); https://mediclassics.kr/books/198/volume/1#content_71 (Shanghan Mingli lun)
• Key point: Co-occurrence of 頭項強痛 and 眩冒; "dizziness is attributed to deficiency"; "those with wind also have dizziness."

Source 5 [KM]

• Source: Beiji Qianjin Yaofang (備急千金要方), vol. 19, "Discourse on the kidney pulse," ch. 1
• Author/Era: Sun Simiao, 652
• MEDICLASSICS: https://mediclassics.kr/books/108/volume/22#content_25 (same passage in Maijing vol. 6: https://mediclassics.kr/books/192/volume/6#content_137)
• Key point: 肩背頸項強痛, 時眩. 取之涌泉崑崙.

Source 6 [KM]

• Source: Hyangyak Jipseongbang (鄕藥集成方), vol. 13, "Dizziness" (quoting Yifang Dacheng)
• Author/Era: Yu Hyo-tong, No Jung-rye, Bak Yun-deok, 1433
• MEDICLASSICS: https://mediclassics.kr/books/93/volume/13#content_258
• Key point: Description of dizziness; headache with stiff nape; "when facing the illness, one must differentiate carefully by pulse and symptoms."

Source 6b [KM]

• Source: Yixue Gangmu (醫學綱目), vol. 11, Liver and Gallbladder, Dizziness—"Externally contracted wind pathogen dizziness" (外感風邪眩) · "Deficiency above dizziness" (上虛眩)
• Author/Era: Lou Ying (樓英), 1565
• MEDICLASSICS: https://mediclassics.kr/books/132/volume/11#content_31 (外感風邪眩); https://mediclassics.kr/books/132/volume/11#content_42 (上虛眩)
• Key point: Places the "Da huo lun" passage 邪中於項 under externally contracted wind dizziness and the "Wei qi" sentence 上虛則眩 under deficiency-above dizziness—the two lineages separated in the classification itself.

Source 7 [WM]

• Source: The Bárány Society position on 'Cervical Dizziness'
• Author/Year: Seemungal BM et al., 2022, Journal of Vestibular Research 32(6):487–499
• Access: DOI (PubMed)
• Key point: Evidence for a mechanistic link between cervical pathology and vertigo is lacking; migraine is the commonest cause; preliminary clinical criteria withheld.

Source 8 [WM]

• Source: Diagnostic accuracy of upper cervical spine instability tests: a systematic review
• Author/Year: Hutting N et al., 2013, Physical Therapy
• Access: DOI (PubMed)
• Key point: Five studies; sufficient specificity, variable sensitivity; no validation in primary care.

Source 9 [WM]

• Source: Manual therapy for cervicogenic dizziness: Long-term outcomes of a randomised trial
• Author/Year: Reid SA et al., 2015 (online 2014), Manual Therapy
• Access: DOI (PubMed)
• Key point: n=86; 12-month DHI −8.9/−13.6 vs placebo; no difference in intensity, pain, or HRA.

Source 10 [WM]

• Source: Effectiveness of adding rehabilitation of cervical related sensorimotor control to manual therapy and exercise for neck pain: A randomized controlled trial
• Author/Year: Sremakaew M et al., 2023 (online 2022), Musculoskeletal Science and Practice
• Access: DOI (PubMed)
• Key point: 152 neck-pain patients; primary outcomes postural sway and JPE; the group adding combined sensorimotor training did best.

Source 11 [WM]

• Source: Evaluation of paraclinical tests in the diagnosis of cervicogenic dizziness
• Author/Year: L'Heureux-Lebeau B et al., 2014, Otology & Neurotology
• Access: DOI (PubMed)
• Key point: 25 cervicogenic vs 25 BPPV; JPE 4.5°, provoked nystagmus 2°/s, Youden 0.60.

Source 12 [WM]

• Source: Comparison of sensorimotor disturbance between subjects with persistent whiplash-associated disorder and subjects with vestibular pathology associated with acoustic neuroma
• Author/Year: Treleaven J et al., 2008, Archives of Physical Medicine and Rehabilitation
• Access: DOI (PubMed)
• Key point: Supports the SPNT as a test of cervical afferent dysfunction.

Source 13 [WM]

• Source: Sensorimotor tests in patients with neck pain and its associated disorders: a systematic review and meta-analysis
• Author/Year: Särkilahti N et al., 2024, Scientific Reports
• Access: DOI (PubMed)
• Key point: 34 studies; the size of the difference depends on pain intensity and the presence of dizziness.

Source 14 [WM]

• Source: Radiographic Indicators of Craniocervical Instability: Analyzing Variance of Normative Supine and Upright Imaging in a Healthy Population
• Author/Year: Gordillo AJ et al., 2025 (online 2024), Clinical Spine Surgery
• Access: DOI (PubMed)
• Key point: 72 subjects, mean age 64; flexion–extension differences in indices; least variance in CXA and hard-palate distances.

Source 15 [WM]

• Source: Craniocervical instability in patients with Ehlers-Danlos syndromes: outcomes analysis following occipito-cervical fusion
• Author/Year: Henderson FC et al., 2024, Neurosurgical Review 47:27
• Access: DOI (PubMed)
• Note: retrospective, uncontrolled
• Key point: 53 selected EDS patients improved in headache, neck pain, vertigo, and dizziness after OCF.

Source 16 [WM]

• Source: Craniocervical instability in patients with Ehlers-Danlos syndromes: outcomes analysis following occipito-cervical fusion of published cases (critique)
• Author/Year: Mughal et al., 2024, Neurosurgical Review
• Access: DOI (PubMed)
• Key point: Points to sample size, absence of control group, and lack of long-term follow-up.

Source 17 [WM]

• Source: Predictive formula of cervical lordosis in asymptomatic young population
• Author/Year: Zhu Y et al., 2020, Journal of Orthopaedic Surgery and Research 15:2
• Access: DOI (PubMed)
• Key point: 307 asymptomatic subjects aged 18–30; CL 17.11° ± 6.31°; regression on T1S, SVA, TIA.

Source 18 [WM]

• Source: The effects of physiotherapy on neck pain with associated symptoms, including cervicogenic dizziness and tinnitus: a systematic review
• Author/Year: Canlı K et al., 2026, BMC Musculoskeletal Disorders
• Access: DOI (PubMed)
• Key point: 13 studies, 785 patients (including tinnitus); 10 at high risk of bias; Mulligan advantage in CROM, no difference in balance.

Source 19 [KM-CN]

• Source: The Efficacy of Acupuncture for the Treatment of Cervical Vertigo: A Systematic Review and Meta-Analysis
• Author/Year: Hou Z et al., 2017, Evidence-Based Complementary and Alternative Medicine
• Access: DOI (PubMed)
• Note: GRADE very low to low
• Key point: 10 RCTs, 914 participants; acupuncture superior to conventional medication; long-term safety uncertain.

Source 20 [WM]

• Source: Orthopedic Physical Assessment, 7th ed. (Magee DJ, Manske RC. Elsevier, 2021)
• Bibliography: Magee DJ, Manske RC. Orthopedic Physical Assessment. 7th ed. St. Louis: Elsevier; 2021. ch. 3 Cervical Spine, pp. 199, 212–214
• Note: textbook
• Key point: List of instability signs; Sharp-Purser, alar ligament, and membrane tests; CCF test specification; no manipulation when instability is present.

Source 21 [WM]

• Source: A System of Orthopaedic Medicine, 3rd ed. (Ombregt L. Elsevier, 2013)
• Bibliography: Ombregt L. A System of Orthopaedic Medicine. 3rd ed. Edinburgh: Churchill Livingstone Elsevier; 2013. Online chapter "Headache and vertigo of cervical origin," e32–e38; ch. 11 "Treatment of the cervical spine," pp. 183–187
• Note: textbook
• Key point: Three-way differentiation of dizziness; turning/stop-turning test; the debate on cervical vertigo as an entity; the debate on vertebral artery testing; rheumatoid ligamentous laxity as an absolute contraindication.

Source 22 [WM]

• Source: Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol. 1, 2nd ed. (Simons DG, Travell JG, Simons LS. Williams & Wilkins, 1999)
• Bibliography: Simons DG, Travell JG, Simons LS. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 1, Upper Half of Body. 2nd ed. Baltimore: Williams & Wilkins; 1999. ch. 7 Sternocleidomastoid, pp. 308–319; ch. 17 Suboccipital, p. 472
• Note: textbook
• Key point: Postural dizziness from clavicular-division trigger points; list of non-vestibular causes; suboccipital trigger points provoked by forward head posture.

Source 23 [WM]

• Source: Imaging Diagnosis of Spinal Disorders (Korean edition ed. Nam Hang-woo, based on Yochum & Rowe, Essentials of Skeletal Radiology)
• Bibliography: Yochum TR, Rowe LJ (Nam Hang-woo, ed. and trans.). Imaging Diagnosis of Spinal Disorders. pp. 18–23 (edition and publisher of the Korean translation to be confirmed)
• Note: textbook
• Key point: ADI adult <3 mm, child <5 mm; McGregor's line; Ruth Jackson's stress lines.

Source 24 [WM]

• Source: Orthopaedic Sports Medicine, 2nd ed. (DeLee JC, Drez D. Elsevier, 2003)
• Bibliography: DeLee JC, Drez D, Miller MD. DeLee & Drez's Orthopaedic Sports Medicine. 2nd ed. Philadelphia: Saunders; 2003. p. 823
• Note: textbook
• Key point: ADI adult <3.0 mm; abnormal motion in 10% of freshman football players; no reliable standard for the upper limit of minor instability.

Source 25 [WM]

• Source: Therapeutic Exercise: Foundations and Techniques (Kisner C, Colby LA); Clinical Orthopaedic Rehabilitation, 3rd ed. (Brotzman SB, Manske RC)
• Bibliography: Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 7th ed. Philadelphia: F.A. Davis; 2018. pp. 515–516 / Brotzman SB, Manske RC. Clinical Orthopaedic Rehabilitation: An Evidence-Based Approach. 3rd ed. Philadelphia: Elsevier Mosby; 2011. p. 460
• Note: textbook
• Key point: Deep cervical flexor activation protocol; Jull CCF reliability ICC 0.81/0.93; improvement in repositioning acuity (Jull 2007b).

Source 26 [WM]

• Source: Muscles: Testing and Function (Kendall FP, McCreary EK), posture chapter
• Bibliography: Kendall FP, McCreary EK. Muscles: Testing and Function. 3rd ed. Baltimore: Williams & Wilkins; 1983. pp. 281–282, 299–300. The copy in the author's library is an excerpt reproduced in Walther DS (Systems DC), The Essentials of Applied Kinesiology in Clinical Practice — Structure course material (1991–1998); page numbers are those of the Kendall original.
• Note: textbook; edition judged to be the 3rd from the printed pagination; verification against the original recommended
• Key point: Kyphosis-lordosis posture (forward head, cervical hyperextension); posterior head tilt; example of mis-corrected forward head posture.

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Choi Jang-hyuk | Doctor of Korean Medicine · Director, Dongjedang Korean Medicine Clinic · Method: DJD multi-literature cross-research