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
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. 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.
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;
Wirbelsaulenklinik Bad Homburg, Kaiser-Friedrich
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
[Article in German] Hulse M, Holzl
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
Mahlstedt K, Westhofen
M, Konig K. Klinik fur
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.
Arch Otorhinolaryngol Suppl
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
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.