Ross Hauser, MD

A person’s balance does not depend only on the inner ear. Safe walking requires the brain to continually integrate information from the eyes, vestibular system, feet, joints, muscles, and cervical spine. The neck supports the head and helps maintain a level gaze, and contains sensory receptors that tell the brain where the head is positioned in relation to the body.

A 2026 study in PLOS One (1) found that experimentally changing cervical posture and restricting neck movement with braces made healthy young adults less stable when they encountered an unexpected treadmill disturbance. The findings do not prove that cervical instability causes falls, but they support the broader concept that cervical posture and movement can influence the body’s ability to recover from a sudden balance challenge.

For patients with chronic neck pain, forward head posture, dizziness, unsteadiness, or a feeling that the floor is moving, this research may help explain why examination of the cervical spine can be an important part of a comprehensive balance evaluation.

Research: cervical posture altered responses to walking perturbations

The August 2026 study included 15 healthy young adults. The researchers used cervical braces to simulate postures associated with cervical lordosis and kyphosis and then tested two types of balance response:

• Participants walked on a treadmill that suddenly decelerated, creating a slip-like perturbation.
• Participants performed a rapid lateral step toward a target, testing goal-directed balance control.

During ordinary, unbraced walking, the treadmill perturbation reduced the participants’ forward margin of stability. Under the braced conditions, however, the margin became negative—an objective indication of instability. Kyphotic bracing also reduced performance as the lateral stepping target became farther away.

The researchers concluded that people wearing cervical immobilization devices or living with cervical deformity may be less able to respond to balance challenges that could precipitate a fall. This does not mean that a cervical collar can cause falls or should not be used when medically necessary. It means immobilization can change normal head and neck mechanics, restrict visual scanning, and alter the coordination used to recover from a disturbance.

This was a small experimental study—not a clinical trial of patients with cervical instability, cervical kyphosis, or degenerative cervical myelopathy. The participants were young and healthy. The braces temporarily simulated aspects of cervical posture but could not reproduce the pain, muscle fatigue, neurological deficits, ligament damage, fear of falling, or long-term compensatory patterns experienced by a symptomatic patient. The study measured laboratory responses rather than actual falls in the community.

An appropriate conclusion is that changing cervical posture and restricting cervical motion can immediately affect some walking-balance responses. Larger studies in older adults and patients with cervical disorders are needed to determine the clinical importance.

Forward head posture, proprioception, and balance

Supportive research extends beyond this single experiment. A systematic review published in October 2022 (2) of 19 studies found consistent evidence that forward head posture was associated with altered limits of stability, poorer performance-based balance, and impaired cervical proprioception. Evidence for static balance, gait, and vestibular dysfunction was less consistent, and experimentally induced forward head posture did not uniformly reduce postural control.

In other words, a person may appear stable while standing quietly yet have difficulty when walking, turning the head, navigating a crowded room, stepping over an obstacle, or recovering from an unexpected slip. Dynamic challenges can reveal problems that a simple static balance test misses.

Proprioception is the nervous system’s ability to sense body position and movement without relying entirely on vision. The upper cervical spine contains a high density of sensory receptors in its muscles, joints, and ligaments. Information from these receptors is integrated with visual and vestibular input to help stabilize the head, eyes, and body.

Following whiplash or another neck injury, abnormal cervical sensory input may contribute to dizziness, unsteadiness, visual disturbance, and altered head-and-eye control. Dr. Julia Treleaven of the University of Queensland concluded in a 2017 review (3) of traumatic neck pain that cervical afferent dysfunction is an important potential contributor to these symptoms, while emphasizing that vestibular, neurological, visual, and other causes must also be considered.

Research using neck-muscle vibration provides additional evidence that changing cervical sensory input can alter balance and gait. In a June 2018 study in the journal Musculoskeletal Science & Practice (4) vibration produced different responses in people with neck pain than in healthy controls, illustrating that the nervous system may reorganize how it uses neck input when pain or dysfunction is present.

Chronic neck pain may change the way a person walks

Patients with chronic neck pain do not always walk normally even when they have no obvious leg injury. Research has found altered trunk rotation and changes in gait, particularly when people are asked to walk while performing a second task (5). This is clinically relevant because during real-world walking, people frequently turn their heads.

Pain may also cause protective muscle guarding. If cervical ligaments or joints do not provide a confident sense of stability, the surrounding muscles may remain tense in an attempt to protect the neck. This stiffness can reduce normal head–trunk dissociation and make it harder to look around while maintaining a smooth walking pattern.

At Caring Medical, we evaluate whether persistent muscle tightness is the primary problem or a protective response to an underlying structural problem. Repeatedly relaxing, stretching, or injecting a guarding muscle may provide only temporary relief if ligament laxity or abnormal vertebral motion continues to activate that muscle.

When imbalance may be a sign of degenerative cervical myelopathy

Not every neck-related balance problem is caused by altered proprioception. Degenerative cervical myelopathy occurs when age-related cervical degeneration compresses the spinal cord. Symptoms can include hand clumsiness, loss of fine motor control, arm or leg weakness, numbness, a heavy-legged or wide-based gait, frequent tripping, and bowel or bladder changes.

Balance and falls are serious concerns in this population. A September 2021 study comparing 340 patients (6) with degenerative spinal disorders with 40 healthy controls found substantially greater head and center-of-mass sway in the patient groups. Balance effort was approximately twice that of controls. In a June 2020 prospective study of patients undergoing surgery for degenerative cervical myelopathy, the fall rate declined from 497.4 to 90.3 falls per 100 person-years after surgery (7). These findings help reinforce that spinal-cord compression can be an important and treatable cause of gait dysfunction. Progressive weakness, worsening gait, loss of hand dexterity, new bowel or bladder dysfunction, saddle numbness, or other signs of spinal-cord compromise require prompt neurological or spine-surgical evaluation.

The Caring Medical perspective: cervical instability and disturbed sensorimotor control

In our 2014 review, we discussed how injured or lax cervical capsular ligaments may permit excessive vertebral movement and contribute to chronic neck pain, muscle spasms, and altered joint function (8). Ligaments do more than hold bones together. They contain sensory nerve endings that participate in proprioception and reflexive muscular stabilization.

When ligamentous input becomes unreliable, the nervous system may receive conflicting information about head and neck position. The muscles may then work harder to stabilize the cervical spine. A patient may experience neck tightness, dizziness, disorientation, visual difficulty, or imbalance—particularly during head movement or upright activity.

Our 2024 Frontiers in Neurology hypothesis paper (9) expanded the cervical-instability model to include progressive loss of the cervical curve, forward head posture, abnormal upper cervical motion, and possible effects on neurovascular and cerebrospinal-fluid pathways. These mechanisms remain under investigation and should not be presented as established explanations for every balance disorder.

In our 2026 retrospective cross-sectional study of 227 patients (10) with chronic brain-based symptoms, all had radiographically identified forward head posture, 90% had reduced cervical lordosis, and 87% had C1–C2 ligamentous cervical instability. Headaches, brain fog, concentration problems, and neck pain were common. The study documented associations within a selected outpatient neck-center population; it did not prove that the cervical findings caused the symptoms or establish that treatment would correct balance dysfunction.

Together, the research supports a clinically useful question: in a patient whose dizziness or imbalance changes with head position, neck movement, or upright posture, could cervical structure and sensorimotor function be contributing factors?

How we evaluate a patient with neck pain and balance problems

A comprehensive evaluation begins by determining whether the symptoms are more consistent with a vestibular disorder, neurological disease, cardiovascular problem, medication effect, visual disorder, peripheral neuropathy, spinal-cord compression, or cervical sensorimotor dysfunction. More than one mechanism may be present.

The history should clarify whether symptoms began after whiplash, concussion, repetitive forward-head activity, or another injury. Important questions include whether imbalance worsens with head rotation, looking upward or downward, walking in darkness, visually busy environments, prolonged computer use, or removing external neck support.

Depending on the presentation, examination may include gait and balance testing, neurological screening, cervical range of motion, joint-position testing, eye-head coordination, and assessment of cervical alignment and stability. Patients with concerning neurological findings may require MRI and referral for neurosurgical evaluation. When standard static imaging does not explain position-dependent symptoms, carefully selected dynamic or upright assessments may provide additional information, although each test has limitations and must be interpreted in clinical context.

For some patients, treatment may appropriately include vestibular rehabilitation, balance training, cervical sensorimotor exercises, posture modification and cervical curve correction, strengthening, or temporary bracing. A 2024 systematic review (11) and meta-analysis found that therapeutic exercise can improve forward head posture and related postural abnormalities, although improved alignment does not automatically mean that dizziness or fall risk will resolve.

When examination suggests symptomatic cervical ligament laxity without progressive myelopathy or another surgical lesion, Prolotherapy may be considered as part of an individualized plan intended to strengthen injured ligament attachments and improve cervical stability.

In this video, Ross Hauser, MD, explains how vision, cervical proprioception, spinal alignment, and neurological input work together to maintain balance—and how cervical instability may disrupt this coordination.

Ross Hauser, MD, illustrates how forward head posture increases stress on the cervical muscles and ligaments and may contribute to progressive loss of the normal cervical curve.

References

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