Traumatic Brain Injury Posture Problems and Solutions

Traumatic Brain Injury, Posture, and Chiropractic-Integrated Care: How Balance Systems, the Neck, and Targeted Rehab Work Together

Overview:

A traumatic brain injury (TBI) can change posture in two major ways. First, it can cause subtle but persistent balance problems that make it difficult to stay centered during standing, walking, or quick head turns. Second, in severe cases, it can trigger rigid “abnormal posturing” like decorticate or decerebrate positions, which are medical emergencies. Even when a TBI is mild, people can struggle for months with postural control because the vestibular, visual, and sensory (proprioceptive) systems in the brain and inner ear are out of sync. Chiropractic-integrated care focuses on restoring spinal alignment—especially in the cervical (neck) and upper thoracic regions—while combining vestibular, visual, and sensorimotor therapies to retrain balance and alleviate symptoms such as dizziness, vertigo, and headaches. (Mount Sinai, 2025; Cleveland Clinic, 2023; Taylor et al., 2022; Brain Injury Canada, n.d.; Mucha et al., 2014)

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What “posture problems after TBI” actually looks like

1) Subtle but persistent balance changes

After a concussion or other TBI, many people notice that standing in a busy store, turning their head quickly, or walking in the dark makes them unsteady. These problems often come from the brain’s sensorimotor integration—how it combines inputs from vision, the inner ear (vestibular system), and body sensors (proprioception). Research shows that balance deficits can persist months or years after mild TBI and are linked to errors in using visual, vestibular, or proprioceptive cues to stay upright. (Campbell et al., 2022; Fino et al., 2022; Taylor et al., 2022; Brain Injury Canada, n.d.)

• People with chronic post-concussion imbalance often score differently on computerized balance tests that stress visual/vestibular inputs. (Campbell et al., 2022; Shirley Ryan AbilityLab, 2013)

• Vestibular dysfunction after mild TBI can include dizziness, imbalance, vertigo, gait disturbance, and abnormal vestibulo-ocular reflexes; vestibular rehab is a recommended treatment pathway in clinical guidelines. (Owens, 2025; VA/DoD, 2024; Taylor et al., 2022)

2) Severe “abnormal posturing” that signals emergency care

In rare, severe head injuries, a patient may show decorticate or decerebrate postures. These are rigid, reflexive positions that indicate serious brain damage and require immediate medical attention. (Cleveland Clinic, 2023; Mount Sinai, 2025)

• Decorticate posturing: arms flexed toward the chest with clenched fists and extended legs. (Cleveland Clinic, 2023)

• Decerebrate posturing: arms and legs held straight and rigid, toes pointed downward, and head and neck arched back. This typically indicates more extensive involvement of the brainstem. Call emergency services right away. (Mount Sinai, 2025)

Bottom line: Most people with TBI do not show abnormal posturing, but even “invisible” balance and posture changes are common and meaningful. (Brain Injury Canada, n.d.)

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Why does balance and posture change after a TBI

The three-system model of upright control

To keep your body centered, your brain blends:

• Vestibular input (inner ear organs that sense head movement),

• Visual input (what your eyes see),

• Proprioception (joint/muscle sensors telling the brain where the body is in space).

TBI can disrupt any of these channels or the brain’s ability to integrate them. Studies in chronic mild TBI show abnormalities in sensory organization and central sensorimotor integration, which explains why patients feel “off balance” even when strength looks normal. (Campbell et al., 2022; Shirley Ryan AbilityLab, 2013; Taylor et al., 2022; Fino et al., 2022)

Common vestibular contributors

• BPPV (loose inner-ear crystals) can occur after TBI and is treatable with repositioning maneuvers. (Taylor et al., 2022)

• Vestibulo-ocular reflex (VOR) deficits are detected using tools such as the video head impulse test (vHIT) and can lead to visual motion sensitivity or blurred vision when the head is moved. (Crampton et al., 2022; Dasgupta et al., 2025)

The neck’s role in posture

The cervical spine is rich in proprioceptors. Cervical injury, inflammation, or malalignment can feed faulty position signals to the brain and trigger cervicogenic dizziness/vertigo, headache, and sense of imbalance—especially after whiplash or head-neck trauma. Evidence and expert reviews describe altered cervical proprioception, and some individuals may benefit from manual therapy and targeted neck sensorimotor exercises, although the entity remains debated. (Cleveland Clinic, 2022; Sung, 2020; Li et al., 2022; Cherchi, 2021; Carrasco-Uribarren et al., 2025)

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Cervical and upper-thoracic misalignment after TBI

How misalignment can worsen symptoms

After a concussion or crash, the neck joints and soft tissues may stiffen or shift out of their normal alignment. In the upper cervical (C0–C2) and upper thoracic regions, this can:

• Disrupt cervical proprioception → dizziness/imbalance (cervicogenic dizziness). (Sung, 2020; Li et al., 2022; Cleveland Clinic, 2022)

• Sensitize nearby muscles and nerves → headaches/neck pain that make it harder to maintain posture. (Li et al., 2022)

• Interact with vestibular dysfunction → vertigo and visual motion sensitivity. (Li et al., 2022; Cleveland Clinic, 2022)

Clinically, Dr. Alexander Jimenez, DC, APRN, FNP-BC, reports that this overlap often presents as neck pain, forward head posture, cervicogenic headache, and dizziness following motor-vehicle or sports injuries, and responds best when the neck and vestibular-visual systems are treated together. (Jimenez, 2018–2025)

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Chiropractic-integrated care: aligning the neck and retraining the balance system

Integrated chiropractic care blends spinal care with vestibular/oculomotor and sensorimotor therapy. Goals are to improve alignment and mobility, calm pain, reset cervical proprioception, and retrain the nervous system so the body can coordinate vision, inner-ear signals, and joint sensation again. (Mucha et al., 2014; Quatman-Yates et al., 2020; HML Functional Care, n.d.; ThinkVida, n.d.; Impact Medical Group, 2024)

1) Spinal assessment and adjustments (with clinical judgment)

• Gentle, targeted adjustments for cervical and upper thoracic segments aim to restore joint motion and reduce local nociception (pain signaling). Some chiropractic sources also propose potential benefits for autonomic regulation and circulatory dynamics, but these mechanisms need more rigorous study; they are best framed as possible rather than proven. (Northwest Florida Physicians Group, n.d.; Impact Medical Group, 2024; HML Functional Care, n.d.)

• Early red-flag screening ensures that people with severe signs (e.g., abnormal posturing, worsening neurological deficits) receive emergency care immediately. (Mount Sinai, 2025; Cleveland Clinic, 2023)

2) Vestibular and oculomotor therapy

• VOMS screening highlights symptom triggers across smooth pursuit, saccades, convergence, VOR, and visual motion sensitivity. (Mucha et al., 2014)

• Treatment can include gaze stabilization, VOR adaptation/substitution, graded optokinetic exposure, and, when appropriate, BPPV maneuvers such as the Epley maneuver. (VA/DoD, 2024; Quatman-Yates et al., 2020; Taylor et al., 2022)

3) Cervical sensorimotor retraining

• Deep neck flexor endurance training, joint position error drills (using a laser/target), postural re-education, and mobility work support proprioceptive normalization. Some trials and reviews suggest that manual therapy combined with exercise may reduce the severity of dizziness in cervicogenic dizziness, although the certainty of the evidence is low to moderate, and this diagnosis remains controversial. (Sung, 2020; Li et al., 2022; Carrasco-Uribarren et al., 2025; Cherchi, 2021)

4) Whole-body balance progressions

• From static stances to dynamic gait with head turns, then dual-task (cognitive) walking, programs systematically stress the visual-vestibular-proprioceptive triad. (Quatman-Yates et al., 2020; Brain Injury Canada, n.d.)

5) Nurse-practitioner oversight and interprofessional care

• Integrated clinics that pair chiropractic physicians with nurse practitioners help address sleep disturbances, mood disorders, migraines, vestibular migraines, medication reviews, and autonomic symptoms. They also coordinate imaging, referrals (including neurology, ENT/audiology, and neuro-optometry), and return-to-work/activity planning. (VA/DoD, 2024; Quatman-Yates et al., 2020; Curran, 2024)

Dr. Jimenez’s observations: In an integrated setting, combining upper-cervical/upper-thoracic adjustments, cervical sensorimotor work, and vestibular/visual rehabilitation improves tolerance for upright time, reduces headache frequency, and helps patients transition from basic stance control to real-world tasks, such as driving or sports. (Jimenez, 2016–2025)

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How TBI-related pain and posture feed each other

Chronic pain is common after TBI and often includes headache, neck pain, and back pain that interfere with rehabilitation and daily activities. Large TBI registry and model system studies estimate ~50–60% of people living with TBI report chronic pain years later, with back and head pain especially frequent. (Hoffman et al., 2024; Curran, 2024)

Pain and stiffness around the neck and upper back can:

• Lower movement confidence and reduced activity, leading to deconditioning and worse balance;

• Increase forward head posture, which strains the cervical extensors and can perpetuate headache and dizziness;

• Heighten sensory “noise,” making it harder for the brain to integrate signals. (Curran, 2024; Brain Injury Canada, n.d.; Li et al., 2022)

An integrated plan that simultaneously targets pain, cervical function, and vestibular deficits supports faster gains in postural control. (Quatman-Yates et al., 2020; VA/DoD, 2024)

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Practical plan: phased care pathway

Always seek emergency care for signs of severe injury (e.g., decerebrate/decorticate posturing, worsening confusion, repeated vomiting, seizures, unequal pupils, or rapidly declining alertness). (Mount Sinai, 2025; Cleveland Clinic, 2023)

Phase 1: Assess and stabilize

• Screen for red flags and abnormal posturing; triage as needed. (Mount Sinai, 2025; Cleveland Clinic, 2023)

• History and exam: symptom triggers (busy visuals, head turns), neck pain, headaches, dizziness, and vertigo.

• VOMS screens for vestibular/ocular deficits; mBESS/BESS or simple stance tests for postural errors. (Mucha et al., 2014; Quatman-Yates et al., 2020)

• Neck exam: range of motion, joint position sense, deep neck flexor endurance, palpation for tenderness/spasm. (Sung, 2020; Li et al., 2022)

Phase 2: Treat drivers and restore alignment

• Cervical/upper-thoracic adjustments and mobilization as appropriate, combined with soft tissue work. (HML Functional Care, n.d.; Impact Medical Group, 2024)

• BPPV maneuvers if indicated. (Taylor et al., 2022)

• Begin cervical sensorimotor drills and gaze stabilization at tolerable levels. (Li et al., 2022; Quatman-Yates et al., 2020)

Phase 3: Progress vestibular and postural load

• Head-turn walking (VOR x1/x2), optic flow exposure, multi-sensory balance (foam/eyes closed), and dual-task gait. (VA/DoD, 2024; Quatman-Yates et al., 2020)

• Postural endurance: scapular and deep neck flexor training to support upright alignment.

Phase 4: Return to complex environments

• Sport- or job-specific balance with visual distractions; graded return to driving or athletics. (VA/DoD, 2024)

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Testing and instruments: from simplest to most advanced

Bedside / low-tech

1. Neurologic exam and mental status, GCS in acute settings; cranial nerves, and motor/sensory testing.

2. Romberg, tandem stance/gait, single-leg stance, and mBESS/BESS to capture postural sway and errors. (Quatman-Yates et al., 2020)

3. VOMS (smooth pursuit, saccades, convergence, VOR, and visual motion sensitivity) to screen vestibular/oculomotor dysfunction. (Mucha et al., 2014)

Clinic-level / specialized
4. Computerized dynamic posturography / Sensory Organization Test (SOT) to quantify reliance on visual, vestibular, and proprioceptive inputs. (Shirley Ryan AbilityLab, 2013)
5. Neck joint position error testing and deep neck flexor endurance for cervical proprioception. (Sung, 2020; Li et al., 2022)
6. vHIT, VEMP (cervical/ocular), calorics, and audiovestibular tests to localize vestibular deficits. (Crampton et al., 2022; Owens, 2025; Taylor et al., 2022)

Imaging / advanced
7. CT/MRI for structural injury in acute/severe cases; advanced MRI (e.g., diffusion) in select persistent cases with specialist guidance. (Mount Sinai, 2025)
8. CSF/ICP monitoring is reserved for severe injuries in hospital settings. (Mount Sinai, 2025)

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Safety notes and expectations

• Most mild TBIs improve, but a subset of individuals experiences long-lasting balance and posture symptoms associated with sensory integration problems. (Campbell et al., 2022; Fino et al., 2022; Taylor et al., 2022)

• Cervicogenic dizziness is a clinically recognized pattern but remains debated; it should be managed using a multimodal, mechanism-informed approach, and central and ear-related causes should always be ruled out. (Cherchi, 2021; Li et al., 2022; Carrasco-Uribarren et al., 2025)

• Chiropractic-integrated care should partner with nurse practitioners and other specialists to address migraine, sleep, mood, medication, and vision therapy needs as necessary. (VA/DoD, 2024; Quatman-Yates et al., 2020; Curran, 2024)

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A day-to-day posture plan you can build on

1. Check alignment daily: Ears over shoulders, gentle chin nods, scapular setting, and periodic posture resets during screens and driving. (Brain Injury Canada, n.d.)

2. Neck program: Deep neck flexor holds, controlled rotation/flexion within pain-free range, and joint position laser drills as taught by your clinician. (Sung, 2020; Li et al., 2022)

3. Gaze training: Start with VOR x1 in a quiet room, then progress to busier settings as tolerated. (Quatman-Yates et al., 2020; VA/DoD, 2024)

4. Walking with head turns: Begin on level ground; add foam or low-light only when earlier steps are comfortable. (Quatman-Yates et al., 2020)

5. Treat BPPV early if positional vertigo is present; relief can be rapid with correct maneuvers. (Taylor et al., 2022)

6. Sleep, hydration, and pacing: These support brain recovery and reduce symptom spikes that undermine posture practice. (VA/DoD, 2024)

Dr. Jimenez’s clinical note: In our integrated clinic, patients who pair cervical/upper-thoracic adjustments with vestibular-visual rehab and neck sensorimotor work tend to regain steady posture faster, report fewer headaches, and tolerate real-world environments sooner. (Jimenez, 2016–2025)

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References

• Brain Injury Canada. (n.d.). [Mobility]. https://braininjurycanada.ca/en/effects-brain-injury/physical/mobility/ braininjurycanada.ca

• Campbell, K. R., King, L. A., Parrington, L., Fino, P. C., Antonellis, P., & Peterka, R. J. (2022). Central sensorimotor integration assessment reveals deficits in standing balance control in people with chronic mild traumatic brain injury. Frontiers in Neurology. https://www.frontiersin.org/articles/10.3389/fneur.2022.897454/full Frontiers

• Carrasco-Uribarren, A., et al. (2025). Is manual therapy effective for cervical dizziness? A systematic review and meta-analysis. BMC Musculoskeletal Disorders. https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-025-08899-z BioMed Central

• Cherchi, M., et al. (2021). The enduring controversy of cervicogenic vertigo, and its place among differential diagnoses of dizziness. Frontiers in Neurology. https://pmc.ncbi.nlm.nih.gov/articles/PMC8544230/ PMC

• Cleveland Clinic. (2022). Cervical vertigo (cervicogenic dizziness). https://my.clevelandclinic.org/health/diseases/23174-cervical-vertigo Cleveland Clinic

• Cleveland Clinic. (2023). Decorticate posturing. https://my.clevelandclinic.org/health/symptoms/24969-decorticate-posturing Cleveland Clinic

• Crampton, A., et al. (2022). Characterizing the evolution of oculomotor and vestibulo-ocular function post-concussion. Frontiers in Neurology. https://www.frontiersin.org/articles/10.3389/fneur.2022.904593/full Frontiers

• Curran, M. C., et al. (2024). Chronic pain after traumatic brain injury: A collaborative care perspective. Frontiers in Rehabilitation Sciences. https://www.frontiersin.org/articles/10.3389/fresc.2024.1398856/full Frontiers

• Dasgupta, S., et al. (2025). Video head impulse test in children—A systematic review. Journal of Clinical Medicine. https://www.mdpi.com/2077-0383/14/2/369 mdpi.com

• Fino, P. C., et al. (2022). Sensory phenotypes for balance dysfunction after mild traumatic brain injury. PLoS ONE. https://pmc.ncbi.nlm.nih.gov/articles/PMC9421603/ PMC

• Flint Rehab. (n.d.). Posturing after brain injury. https://www.flintrehab.com/posturing-brain-injury/ Flint Rehab

• HML Functional Care. (n.d.). How chiropractic neurology supports brain healing. https://hmlfunctionalcare.com/how-chiropractic-neurology-supports-brain-healing/ pinnaclehealthchiro.com

• Hoffman, J. M., et al. (2024). Collaborative Care for Chronic Pain After TBI. JAMA Network Open. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2819403 jamanetwork.com

• Impact Medical Group. (2024). Can chiropractic care help with mild TBIs? https://www.impactmedicalgroup.com/2024/06/26/can-chiropractic-care-help-with-mild-traumatic-brain-injuries/ HML Functional Care

• Jimenez, A. (2016–2025). Selected clinical posts (cervicogenic dizziness; TBI; vestibular care; posture). https://dralexjimenez.com/ (examples: 1, 2, 3) El Paso, TX Doctor Of Chiropractic+2El Paso, TX Doctor Of Chiropractic+2

• Li, Y., et al. (2022). Proprioceptive cervicogenic dizziness: Pathogenesis, diagnosis, and treatment. Journal of Clinical Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC9655761/ PMC

• Mount Sinai. (2025). Decerebrate posture. https://www.mountsinai.org/health-library/symptoms/decerebrate-posture Mount Sinai Health System

• Mucha, A., et al. (2014). A brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions. The American Journal of Sports Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC4209316/ PMC

• Northwest Florida Physicians Group. (n.d.). Using chiropractic care to treat TBIs. https://northwestfloridaphysiciansgroup.com/using-chiropractic-care-to-treat-traumatic-brain-injuries/ HML Functional Care

• Quatman-Yates, C. C., et al. (2020). Physical therapy evaluation and treatment after concussion/mTBI. Journal of Orthopaedic & Sports Physical Therapy. https://www.jospt.org/doi/10.2519/jospt.2020.0301 JOSPT

• Shirley Ryan AbilityLab. (2013). Sensory Organization Test (SOT). https://www.sralab.org/rehabilitation-measures/sensory-organization-test Shirley Ryan AbilityLab

• Sung, Y.-H. (2020). Upper cervical spine dysfunction and dizziness. Journal of Exercise Rehabilitation. https://pmc.ncbi.nlm.nih.gov/articles/PMC7609854/ PMC

• Taylor, R. L., et al. (2022). Patterns of vestibular dysfunction in chronic TBI. Frontiers in Neurology. https://www.frontiersin.org/articles/10.3389/fneur.2022.942349/full Frontiers

• U.S. VA/DoD. (2024). Assessment and management of dizziness/visual disturbances following concussion; mTBI guidelines. https://health.mil/Reference-Center/Publications/2024/02/23/Assessment-and-Management-of-Dizziness-and-Visual-Disturbances-Following-Concussion-Mild-Traumatic-Brain-Injury and https://www.healthquality.va.gov/guidelines/rehab/mtbi/ Health.mil+1

(Additional useful clinical summaries referenced in-text: Impact Medical Group (2024), ThinkVida (n.d.), Pinnacle Health Chiropractic (n.d.).) HML Functional Care