frequently used interchangeably, they are two separate and distinct entities.
Dizziness usually refers to a sense of faintness, giddiness or lightheadedness,
while vertigo is usually expressed as a "whirling" sense of movement.
While we have all experienced dizziness, vertigo is often wrongly confused to
be the same sensation. The best analogy to describe the sensation of vertigo is
the following: Imagine yourself spinning on a merry-go-round and then you step off
quickly. You continue to feel like your spinning around in circles. This is
true vertigo. Both can be caused by many clinical conditions ranging from:
cardiovascular, neurological or endocrine disorders to certain types of
medications and adverse drug reactions. Most often, they are usually caused by
problems in the inner ear or from the structures of the neck.
Balance and Equilibrium
Your body coordinates three sources of sensory information to establish
coordination, balance and equilibrium. Information from your eyes, your inner
ears, and the joints of your body all supply information to the brain. A
problem in any one of these three areas, can send "incorrect"
information to your brain and give you symptoms of disequilibrium. As stated
previously, there are many causes of dizziness and vertigo, but most often they
involve the inner ear or the joints of the neck.
Can Chiropractic Help Vertigo and Dizziness?
The body has special nerve sensors called proprioceptors that are richly
invested in the structural tissues of the body. They function to send
information to the brain about position and movement sense of the body. These
receptors are most heavily concentrated in and around the joints of your body.
When your joints are dysfunctional and not moving properly, altered sensory
information is sent to your brain, which can create disequilibrium (vertigo and
dizziness). This is often seen in the neck as cervicogenic vertigo (vertigo
caused from the neck). Chiropractic is extremely effective at helping
cervicogenic vertigo by addressing dysfunctional neck structures.
Clinically, the most common type of vertigo seen in this office is Benign
Vertigo, or Benign Paroxysmal Positional Vertigo (BPPV). Benign vertigo is
theorized to be caused by small densities (Canolith, litho=stone) that are
formed inside the inner ear. Most often as a result of head trauma, recently or
in the past. What usually initiates the episode of vertigo is that the head is
placed in an awkward position for a prolonged period of time, either from an
unusual sleeping position, or some other activity, for example: painting a
ceiling with your head in prolonged extension. It is theorized that these
"stones" migrate into areas of the inner ear and cause trouble with
the vestibular apparatus or organ of balance. And thereby send false signals of
movement, when the body is not moving.
for Benign Vertigo: The Canalith Repositioning Procedure...
The canolith repositioning procedure is not a chiropractic procedure, but a
procedure first instituted and described by John M. Epley, M.D. The procedure
is basically a manual head positioning procedure designed to move these
densities out of sensitive areas of the inner ear, into areas that do not cause
problems. Clinically, I have been very successful treating benign paroxysmal
positional vertigo in the office. Most patients experience immediate results,
while only a handful require one to two more visits. About half experience a
relapse, usually around 3-6 months, that quickly goes away with further
treatment. The procedure is painless. If you can lie on your back, rollover on
your side, lie face down, while having your head supported in a variety of
positions, you will do fine.
My interest in vestibular disorders first began in graduate school; my wife
woke up one morning with severe vertigo for the very first time. After a trip
to an otolaryngologist, (ears, nose, throat specialist, or E.N.T.) and further
diagnostic testing, not much was done, only medication was prescribed such as
Antivert, which was not very effective, and had side effects also. A
Neurologist instructor of mine suggested I do further research into it so I
traveled to the University of Iowa Medical Center Library, and researched
articles on treatment. That is when I came across Dr. Epley's canolith
repositioning procedure. As of 2006, I have treated approximately 300 people. I
would estimate 80% have had immediate cessation of their vertigo on their first
visit, while 15% required an additional two to five visits for complete
resolution. Of the remaining patients, a few were unable to perform the
required positioning (elderly) and received no benefit. Some had signs and
symptoms that were not related to the inner ear. One patient had cervicogenic
(caused by the neck) vertigo, and two were unresponsive to the Epley procedure.
I have had only two patients that have gotten worse temporarily.
I have been most disappointed that most, if not all, doctors know nothing about
treating this affliction with this relatively simple and effective manual
method. Of all the E.E.N.T. specialists my patients have seen, they have never
performed this procedure. One E.E.N.T. told my patient to hang her head off the
edge of the bed, and that was it! I would think that something that is directly
in their scope of practice would deserve a complete knowledge of all treatments
available. She was most displeased and came to me and walked out free of
vertigo. Most of the patients I have seen have been seen by their family
doctor, then referred to E.E.N.T. specialists, and neurologists with no help. I
have received many referrals from the physicians in my group office with excellent
results. I am always looking for an E.E.N.T. specialist that I can refer to if
I have a difficult case.
Articles on Vertigo
- The canalith repositioning
procedure: for treatment of benign paroxysmal positional vertigo.
John M. Epley, M.D., Portland Otologic Clinic, Portland, Oregon
Otolaryngol Head Neck Surg, 1992 Sep, 107:3, 399-404
The Canalith Repositioning Procedure (CRP) is designed to treat benign
paroxysmal positional vertigo (BPPV) through induced out-migration of
free-moving pathological densities in the endolymph of a semicircular
canal, using timed head maneuvers and applied vibration. This article
describes the procedure and its rationale, and reports the results in 30
patients who exhibited the classic nystagmus of BPPV with Hallpike
maneuvers. CRP obtained timely resolution of the nystagmus and positional
vertigo in 100%. Of these, 10% continued to have atypical symptoms,
suggesting concomitant pathology; 30% experienced one or more recurrences,
but responded well to retreatment with CRP. These results also support an
alternative theory that the densities that impart gravity-sensitivity to a
semicircular canal in BPPV are free in the canal, rather than attached to
the cupula. CRP offers significant advantages over invasive and other
noninvasive treatment modalities in current use.
- Epleys manoeuvre for benign
paroxysmal positional vertigo: a prospective study.
Wolf M, Hertanu T, Novikov I, Kronenberg J. Department of
Otorhinolaryngology/Head and Neck Surgery, Sheba Medical Center, Tel
Clin Otolaryngol 1999 Feb;24(1):43-6
The treatment of benign paroxysmal positional vertigo (BPPV) by the Epley,
canalith repositioning, manoeuvre was popularized following clinical
reports which demonstrated a significant success rate. Benign paroxysmal
positional vertigo is considered a self-limiting disease, yet only few
authors have analysed the effect of this manoeuvre in randomized,
controlled terms. A prospective 3-year, controlled study of patients with
BPPV of long duration (mean = 6 months) verified its benefit: the recovery
course differed significantly between a group of 31 patients treated with
the manoeuvre and a control group of 10 untreated patients. Symptoms
subsided within 72 h in 35% and within a week in 74% of patients after one
session of treatment. Only two treated patients (6.5%) did not recover
versus a 50% failure rate among untreated patients (P = 0.0005). The rate
of recovery was not affected by the duration of symptoms before initiation
of treatment, or by the patient's age and gender.
- Success of the modified Epley
maneuver in treating benign paroxysmal positional vertigo.
Wolf JS, Boyev KP, Manokey BJ, Mattox DE. Division of Otolaryngology-Head
and Neck Surgery, University of Maryland Medical System, Baltimore, USA.
Laryngoscope 1999 Jun;109(6):900-3
OBJECTIVE: Benign paroxysmal positional vertigo (BPPV) is a common
condition seen by otolaryngologists. The purpose of this study is to
determine the ability of the modified Epley maneuver to treat BPPV. STUDY
DESIGN: Retrospective review. METHODS: A retrospective chart review of 107
patients diagnosed with BPPV at our institution between March of 1993 and
June of 1995. Each patient was diagnosed with isolated BPPV by history and
Dix-Hallpike maneuver. There were no other vestibular symptoms or
electronystagmogram abnormalities. Patients diagnosed with BPPV received
modified Epley maneuvers, were instructed to remain upright for 48 hours,
and wore a soft collar for a week. Patients were followed up with repeat Dix-Hallpike
maneuvers at 1 to 2 weeks. If symptoms persisted, the maneuver was
repeated for up to a maximum of three times, at which point patients were
considered to have failed treatment. RESULTS: The average age of patients
was 57.8 years old. Thirty percent were male and the right ear was
affected in 54%. The posterior semicircular canal was affected in 105
ears. The average patient received 1.23 Epley maneuvers, with a success
rate of 93.4%. No successfully treated patients received mastoid
vibration. Seven out of 107 patients failed after three Epley maneuvers.
Two failure patients had a history of temporal bone fracture. Two failure
patients were treated with posterior semicircular canal block surgery. CONCLUSION:
The modified Epley maneuver is an excellent treatment for BPPV.
- Single treatment approaches to
benign paroxysmal positional vertigo.
Herdman SJ; Tusa RJ; Zee DS; Proctor LR; Mattox DE. Department of
Otolarygology-Head and Neck Surgery, Johns Hopkins Hospital, Baltimore,
Arch Otolaryngol Head Neck Surg, 1993 Apr, 119:4, 450-4
OBJECTIVE--To determine the effectiveness of two different physical
therapy approaches for benign paroxysmal positional vertigo.
DESIGN--Randomized study. SETTING--Outpatient clinic. PATIENTS--Consecutive
sample of 60 patients with benign paroxysmal positional vertigo.
INTERVENTION--Patients received either a single treatment based on the
hypothesis that the vertigo and nystagmus of benign paroxysmal positional
vertigo are due to debris adhering to the cupula of the posterior
semicircular canal (cupulolithiasis) or a single treatment based on the
hypothesis that the debris is free floating in the long arm of the
posterior canal (canolithiasis). Patients were reevaluated 1 to 2 weeks
after the treatment and again 4 to 6 months later. OUTCOME--Treatment
outcome was classified as either asymptomatic, more than 70% improved as
rated by the patient, or no change. RESULTS--The treatment designed for
cupulolithiasis resulted in remission of vertigo and nystagmus in 70% of
the patients and in improvement of the symptoms in another 20%. The
treatment designed for canalithiasis resulted in remission of vertigo and
nystagmus in 57% of the patients and in improvement in another 33%. There
was no statistically significant difference between treatments. CONCLUSIONS--These
single-treatment approaches are equally effective treatments for benign
paroxysmal positional vertigo. Further studies are needed to look at
the long-term effectiveness of these treatments.
- Vertigo in patients with
cervical spine dysfunction.
Galm R; Rittmeister M; Schmitt E
Wirbelsaulenklinik Bad Homburg, Kaiser-Friedrich Promenade, Germany.
Eur Spine J 1998;7(1):55-8
To our knowledge, quantitative studies on the significance of disorders of
the upper cervical spine as a cause of vertigo or impaired hearing do not
exist. We examined the cervical spines of 67 patients who presented with
symptoms of dizziness. Prior to the orthopaedic examination, causes of
vertigo relating to the field of ENT and neurology had been ruled out.
Fifty patients of the above-mentioned group were studied. They followed
the outlined treatment protocol with physical therapy and were available
for 3 months of follow-up. Thirty-one patients, hereinafter referred to as
group A, were diagnosed with dysfunctions of the upper cervical spine.
Nineteen patients, hereinafter referred to as group B, did not show signs
of dysfunction. Cervical spine dysfunctions were documented as published
by Bischoff. In group A dysfunctions were found at level C1 in 14 cases,
at level C2 in 6 cases and at level C3 in 4 cases. In seven cases more
than one upper cervical spine motion segment was affected. Dysfunctions
were treated and resolved with mobilising and manipulative techniques of
manual medicine. Regardless of cervical spine findings seen at the initial
visit, group A and B patients received intensive outpatient physical
therapy. At the final 3-month follow-up, 24 patients of group A (77.4%)
reported an improvement of their chief symptom and 5 patients were
completely free of vertigo. Improvement of vertigo was recorded in 5 group
B patients (26.3%); however, nobody in group B was free of symptoms. We
concluded that a functional examination of motion segments of the upper
cervical spine is important in diagnosing and treating vertigo, because a
non-resolved dysfunction of the upper cervical spine was a common cause of
long-lasting dizziness in our population.
- Vestibulospinal reactions in
cervicogenic disequilibrium. Cervicogenic imbalance.
[Article in German] Hulse M, Holzl M
Abteilung fur Phoniatrie, Padaudiologe und Neurootologie,
HNO 2000 Apr;48(4):295-301
A functional cervical spine disorder is often the cause for persistent
vertigo, which can last months or several years. The existence of cervical
vertigo is not generally recognized, mainly because an objectivation of
the cervical nystagmus is not easily understood by many examiners. In this
study we examine additional parameters, which underline the diagnosis of
cervical imbalance. The anamnestic statement of staggering refers to a
disturbance of the vestibulospinal reactions. In 67 patients in which
cervical imbalance was suspected the vestibulospinal reactions were
monitored directly before and after manual therapy of the cervical spine.
The cranio-corpo-graphie (CCG) and the posturography were used to monitor
the results. A highly significant improvement of pathological
vestibulospinal reactions was seen after chiropractic manipulation of the
spine. These results show that a functional disorder of the cervical
vertebrae influences the vestibulospinal reactions. The pathological
deficit of the vestibulospinal reactions is not solely a phenomenon of
peripheric labyrinth malfunction, failure in the brainstem or in the area
of the cerebellum ("brain stem staggering"), but can also be
viewed nearly regularly by cervical disturbance of the equilibrium. The
results of the treatment can be observed within a few hours.
- Therapy of functional disorders
of the craniovertebral joints in vestibular diseases.
Mahlstedt K, Westhofen M, Konig K. Klinik fur Hals-Nasen-Ohrenkrankheiten,
Laryngorhinootologie 1992 May;71(5):246-50
Cervicogenic vertigo is caused by functional disorders of the
craniovertebral joints. Improvement of vertigonous symptoms by
chiropractic treatment was often described. The therapeutic effect of
chiropractic treatment in 28 patients with vertigo and purely functional
disorders of the upper cervical spine or with a combination of functional
disorders of the upper cervical spine and the labyrinth was evaluated.
Improvement of vertigonous symptoms on patients with purely functional
disorders of the craniovertebral joints as well as on patients with
combined functional disorders of the craniovertebral joints and labyrinth
could be seen. Two of the 28 patients showed persistent relief of symptoms
and normalisation of cervical motility whereas the vestibular deficit
persisted. One patient with persistent vestibular dysfunction showed
recurrent malfunction of the upper cervical spine and vertigo. In our
opinion chiropractic treatment is mandatory for the therapy of patients
with vestibular affections and functional disorders of the craniovertebral
- Neck-induced vertigo.
Arch Otorhinolaryngol Suppl 1985;2:107-24
Cervicogenic vertigo can be elicited by hyperactivity of spinovestibular
afferents and, much more seldomly, by episodic reduction of blood flow in
the vertebral artery. The afferent hyperactivity to the vestibular system
derives from a "circulus vitiosus" involving false posture,
pain, joint dysfunction, which in turn exacerbates the false posture - and
so on. This is to be observed in the joints CO/C1 and C1/C2 and their
short muscles. This dysfunction of the upper cervical spine can be
determined by exact anamnesis, careful investigation of neck mobility,
joint play and muscle tension. The cervical nystagmus observed during the
neck torsion test is short (seconds) in functional diseases
(hyperactivity) and long-lasting (minutes) in cases of vascular disorder.
Cervical vertigo should be differentiated from other atactic disorders,
especially those arising from benign paroxysmal positional vertigo and
from Meniere's disease.
- A combined approach for the
treatment of cervical vertigo.
Bracher ES, Almeida CI, Almeida RR, Duprat AC, Bracher CB
J Manipulative Physiol Ther 2000 Feb;23(2):96-100
BACKGROUND: Cervical vertigo is a diagnosis commonly made at both
otorhinolaryngologist and chiropractic offices. Hypothesized non-vascular
mechanisms are reviewed. Therapeutic approaches have been suggested in the
literature, ranging from cervical immobilization to vertebral
manipulation. OBJECTIVE: To characterize the patient population with cervical
vertigo and observe therapeutic results of a treatment protocol by using
distinct conservative modalities. METHODS: Fifteen subjects with cervical
vertigo were selected from patients presenting with dizziness at an
otorhinolaryngology medical office. Diagnosis was based on specific
criteria and results of an otoneurologic examination. All patients were
submitted to a treatment protocol, including spinal manipulation, manual
therapy on affected muscle groups, analgesic electrotherapy, labyrinth
sedation, surface electromyography biofeedback, and an exercise program.
Evolution of dizziness complaints and related musculoskeletal dysfunction
was observed. RESULTS: Musculoskeletal complaints were present in 93% of
the patients, mainly cervical pain, shoulder-girdle pain, and tension-type
headache. Median duration of musculoskeletal symptoms was 7.5 years,
whereas the median duration of dizziness before the beginning of treatment
was 52 days. Treatment duration averaged 5 sessions and 41 days. At the
end of treatment, 60% of patients reported remission, 20% reported
consistent improvement of vertigo. Remission of musculoskeletal symptoms
was observed in 26.7% of patients, and improvement was observed in 60% of
patients. CONCLUSION: Chronic, non-traumatic, cervical and shoulder-girdle
dysfunction was an important causal and perpetuating factor of cervical
vertigo in the population studied, and a consistent improvement was
observed with the use of a conservative treatment protocol involving
multiple modalities for patients with cervical vertigo. Further controlled
studies are needed to access its validity.