Vertigo & Chiropractic

 Vertigo and Chiropractic.

Not many people would discuss vertigo and Chiropractic in the same sentence. This maybe due to a lack of understanding regarding the possible causes of vertigo, never mind then think to themselves: “I’d better go see my chiropractor about it”.

I have noticed a lot of confusion surrounding vertigo and dizziness in my clinical career. This confusion is regarding if there is even a difference between dizziness and vertigo, the causes for both and more importantly, the diagnosis and treatment for both. This blog delves into the causes, symptoms, diagnosis, and treatment of the most common cause of vertigo known as benign paroxysmal positional vertigo, or BPPV. The reason we are focusing on BPPV because if the most common type of vertigo and, more importantly, because there is a basically a mechanical cause for it, chiropractic and other manual therapies have been found to be beneficial in its management.

Vertigo VS Dizziness

As some people don’t know, there is a difference between dizziness and vertigo, so it is important that we start with a clear definition and understanding of these conditions and their differences.

Dizziness is defined as the sensation of altered or impaired spatial orientation without a false sense of motion^1,2.  Dizziness is a relatively common disorder affecting approximately 23% of adults in the UK annually². Vertigo however is more than the sensation of feeling dizzy. The best way I can think of to describe the sensation of vertigo to patients is true vertigo is the spinning sensation that we experience after having a few too many alcoholic beverages on a Saturday night. That horrible sensation of the room spinning around you while you are stationary is vertigo.

Vertigo is therefore a symptom of something, rather than a disease itself. It indicates a problem in the vestibular system, which includes parts of the inner ear and brain responsible for controlling balance and eye movements. Vertigo can be classified into two main types:

1. Peripheral Vertigo: Caused by problems in the inner ear.
2. Central Vertigo: Originating in the brain or spinal cord.

For the purposes of this blog, we will focus our attention on peripheral vertigo because there are several causes of peripheral vertigo that can be helped without medication.

FYI, the reason alcohol causes vertigo is because alcohol intoxication gradually impairs cognitive function, along with inner ear dysfunction³. The inner ear apparatus, known as the vestibular apparatus in three canals, filled with fluid with tiny hairs that sense the displacement of the fluid. The stimulation of the hairs sends signals to the brain regarding position sense and telling your brain here your head is in space. It is part of your balance system and positional sense, known medically as proprioception. The reason alcohol causes vertigo is because alcohol (ethanol) has a lower density (also known as specific gravity) than water. As the concentration of alcohol increases, the water in the vestibular apparatus becomes displaced by the alcohol causing altered movements and stimulus of the tiny hairs, leading to dizziness and vertigo. Roth et al (2014) concluded in their study that alcohol consumption also systematically impairs head and eye movement reflexes, contributing towards the gradual loss of balance and impaired movements⁴. These findings have been confirmed by further studies into the neurological dysfunctional effects of alcohol consumption³.

Benign Paroxysmal Positional Vertigo (BPPV) is a common cause of vertigo, characterized by brief episodes of this spinning sensation related to changes in head position. Despite its unsettling symptoms, BPPV is generally benign and manageable with appropriate treatment.

What is BPPV?

BPPV is a disorder of the inner ear that leads to short, intense episodes of vertigo⁵. BPPV is the most common cause of peripheral vertigo⁶. The term “benign” indicates that it is not life-threatening, “paroxysmal” refers to the sudden onset of symptoms, and “positional” signifies that symptoms are triggered by changes in head position. BPPV occurs when tiny calcium carbonate crystals, called otoconia or canaliths, become dislodged from their usual location in the utricle (part of the inner ear) and migrate into one of the semicircular canals of the inner ear. These crystals interfere with the normal fluid movement that the inner ear uses to sense head motion, causing vertigo. This is similar to the effect alcohol consumption has on the fluid movement in the semicircular canals.

Causes of BPPV

The exact cause of BPPV is not always clear, but several factors can contribute to the dislodgement of otoconia:

• Head Injury: Trauma to the head can displace the otoconia.
• Age: The condition is more common in older adults, possibly due to the natural degeneration of the otolith organs in the inner ear.
• Inner Ear Disorders: Conditions like labyrinthitis or Meniere’s disease can increase the risk.
• Prolonged Bed Rest: Extended periods of lying down, such as in a hospital stay, can lead to the movement of otoconia.

Symptoms of BPPV

The hallmark symptom of BPPV is vertigo triggered by specific changes in head position. It typically occurs when getting into or out of bed going from an upright to and horizontal position. Other common head positions include when someone may be looking up and turning their head simultaneously. Other symptoms may include:

• Dizziness: A sensation of spinning or moving.
• Nausea and Vomiting: Often accompanying the vertigo.
• Balance Problems: Feeling unsteady or off-balance.
• Nystagmus: Involuntary, rhythmic eye movements often observed during an episode.

These episodes typically last less than a minute but can be intense and distressing. The episodes can be scary and cause some people to be scared to perform certain movements they know can or will set off this horrible sensation. I have even had some patients who are so worried about setting off their episodes that they spend weeks sleeping in an upright position, so they don’t have to lie down.

Diagnosing BPPV

Diagnosis of BPPV involves a combination of medical history, physical examination, and specific tests to provoke and observe the symptoms:

Dix-Hallpike Test

This is the most common test for BPPV. During the test, the patient is quickly moved from a sitting to a lying position with the head turned to one side and slightly extended. The clinician observes for nystagmus and asks about vertigo symptoms. A positive test indicates BPPV. This test not a pleasant experience as it is designed to set off an attack of vertigo. I always warn patients of this before starting the test and have a bucket present in case of an event of vomiting.

Roll Test

For diagnosing BPPV affecting the horizontal semicircular canal, the roll test involves moving the patient’s head from side to side while they lie on their back. This test helps identify which ear is affected.

Treatment Options for BPPV

Treatment for BPPV focuses on repositioning the dislodged otoconia back to their correct location in the inner ear. The following manoeuvres are commonly used:

Epley Manoeuvre

The Epley manoeuvre is a series of specific head and body movements designed to guide the otoconia out of the semicircular canal and into the utricle. This manoeuvre is highly effective and can be performed in a clinical setting or at home with proper guidance. This is the most common manoeuvre I perform in clinic with my patients with BPPV. It is very simple to perform and can provide immediate relief from their vertigo symptoms. However, sometimes the Epley manoeuvre may need to be repeated a few times in one day, or over the course of several days to achieve the best outcome.

Managing BPPV and Preventing Recurrence

While BPPV can be effectively treated, recurrence is common. Here are some tips for managing and preventing BPPV:

• Avoid Triggers: Try to avoid sudden head movements and positions that trigger symptoms.
• Stay Active: Gentle, regular physical activity can help maintain inner ear balance.
• Hydration and Nutrition: Maintain a healthy diet and stay hydrated to support overall vestibular health.
• Follow-Up: Regular follow-ups with a healthcare provider can help monitor the condition and manage recurrences.

Conclusion

BPPV is a common and manageable condition that can cause significant disruption to the sufferer’s life. Understanding the causes, symptoms, and treatment options is crucial for effective management. With proper diagnosis and treatment, most people can find relief from BPPV and return to their normal activities. If you experience symptoms of BPPV, consult with a healthcare professional or call us at Spriggs Chiropractic on 01635 4323 or email hello@spriggschiropractic.co.uk to explore your treatment options and take the first step towards regaining your balance and well-being.

I hope you enjoyed this blog post. There has been a significant increase in the number of patients presenting to the clinic with vertigo over the course of this year. It therefore felt prudent to write this blog and get some information out there about it to inform people about the condition, but also reassure people that it can be easily managed.

For more information on how to manage your vertigo check out the NHS website on vertigo for some simple tips to help those of you who are really struggling with your symptoms.

By Mark Spriggs DC, MChiro, MSc, PGCert, FRCC

References:

1. Happonen T, Nyman M, Ylikotila P, Mattila K, Hirvonen J. Imaging Outcomes of Emergency MR Imaging in Dizziness and Vertigo: A Retrospective Cohort Study. Am J Neuroradiol. 2024;45(6):819-825. doi:10.3174/ajnr.a8202
2. Bisdorff A, Von Brevern M, Lempert T, Newman-Toker DE. Classification of vestibular symptoms: Towards an international classification of vestibular disorders. J Vestib Res Equilib Orientat. 2009;19(1-2):1-13. doi:10.3233/VES-2009-0343
3. Ojanperä OAI, Salonen JN, Haavisto L, Sarin J. Ethanol-Induced Vestibular Dysfunction as a Model for Bilateral Vestibular Syndrome: Similarities in Video Head Impulse Test and Video-Oculography Data. J Int Adv Otol. 2023;19(5):388-395. doi:10.5152/iao.2023.231030
4. Roth TN, Weber KP, Wettstein VG, Marks GB, Rosengren SM, Hegemann SCA. Ethanol consumption impairs vestibulo-ocular reflex function measured by the video head impulse test and dynamic visual acuity. J Vestib Res Equilib Orientat. 2014;24(4):289-295. doi:10.3233/VES-140520
5. Fowler TJ. Positional Vertigo. In: Clincal Neurology. 3rd ed. Arnold; 2003:202-203.
6. Varghese SS, Varghese A, Kumar N. Adoption of the international classification of vestibular disorders criteria in cases of Benign positional paroxysmal vertigo: a single-center experience. Eur Arch Oto-Rhino-Laryngology. Published online 2024:5717-5721. doi:10.1007/s00405-024-08794-8