Vertigo and Dizziness

Although 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.

Coordination, 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.

How 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.

Treatment 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.

Comments...

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. I have successfully treated more than 600 people since 1997. I have had patients travel in from other states for treatment. Most of the patients I have seen have been seen by their family doctor, an E.N.T. and other specialists such as neurologists with no help. I currently receive referrals from existing patients, the physicians in my group office and referrals from other doctors in the community, including a local neurologist.

Medline 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 Hashomer, Israel.
  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, MD.
  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, Universitats-HNO-Klinik Mannheim.
  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, Universitats-Krankenhauses Hamburg-Eppendorf.
  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 joints.
• Neck-induced vertigo.
  Scherer H
  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.