Dizziness, Vertigo, Tinnitus, Meniere's Disease an

• Vertigo is a common symptom presenting in chiropractic patients, especially after head and neck trauma, and in most cases is a treatable condition. It is most common among the elderly, but it can also affect men and women of all ages. Often, it is an early symptom of an inner ear or neurological problem. Vertigo and dizziness can be upsetting, uncomfortable and a very disabling complaint. It is a sense of dizziness or spinning while stationary, sometimes associated with symptoms such as nausea, tinnitus, vomiting, sweating, fatigue and headaches.

                                       Click here for "WebMD: A Visual Guide to Balance Disorders"

                                       Click here for "Are Your Ears Ringing? It Might Be Tinnitus"

                                                  Click here for additional 'Tinnitus' information"

                                         Click here for infographic "wikiHow to Relieve Tinnitus"

There are two types of vertigo that chiropractic care can try to correct. These are benign paroxysmal positional vertigo (BPPV) and cervicogenic vertigo. By far the most common type of vertigo is BPPV. Chiropractors are trained to differentiate between these types of vertigo using orthopaedic tests and to rule out other potential causes of dizziness (and refer if necessary).

Other Types of Vertigo:

• Treatment for vertigo caused by other conditions depends on the individual case. It is important to determine the cause of dizziness such that an appropriate solution is found.
• Ménière’s disease patients can benefit from a low-salt diet.
• Treatment for vertigo associated with migraine headaches (which may also be related to poor neck mechanics, cervical osteoarthritis or advancing spinal disc disease) should include dietary changes, such as reduction or elimination of aspartame, chocolate, alcohol and caffeine, in addition to exercise, soft tissue and osseous mobilization techniques, stress reduction, adequate sleep, and vestibular rehabilitation exercises.
• Vestibular neuronitis and labyrinthitis, which are often attributed to viral infections, can also be treated with vestibular exercises.
• Working with your doctor of chiropractic to improve postural issues can also bring relief to the patients whose vertigo is exacerbated by sedentary lifestyle or working in certain positions for extended periods.
• In patients with cervicogenic vertigo, a general ergonomic assessment of work and life activities can help identify the factors contributing to the problem.

Causes of Vertigo:

• Vertigo can be caused by many problems, most of which originate in the peripheral or central nervous system.
• The causes of vertigo that stem from the peripheral nervous system include benign paroxysmal positional vertigo (BPPV), acute vestibular neuronitis, labyrinthitis and Ménière’s disease.
• Acoustic neuroma, migraines, cervicogenic vertigo and multiple sclerosis are all related to the central nervous system. Click here for a research abstract with respect to " Cervical-induced vertigo may be caused by degenerative or functional disorders of the cervical spine".
• With respect to cervicogenic vertigo producing dizziness that arises from the neck, irritation or injury to the joints... muscles or ligaments of the neck can overstimulate proprioceptors (nerve endings that detect position sense) in the neck giving rise to vertigo.
• Insufficient hydration tends to increase the frequency and intensity of vertigo episodes.
• Inner ear viral infection.
• Insufficient blood flow to the brain (ischemia).
• Vertigo can also be caused by a wide variety of medications such as antidepressants, anticonvulsants, antihypertensives, diuretics, barbiturates, salicylates (e.g., aspirin), sedatives or hypnotics, some antibiotics taken in high doses over prolonged periods of time can damage the vestibular system, some prescription and over-the-counter cold medicines, and some antibiotics and antineoplastics.
• Low blood pressure, low blood sugar (hypoglycemia), anemia, anxiety, multiple sclerosis, diabetes mellitus, hypothyroidism, high blood triglycerides, food allergies or gluten sensitivity, and various inner ear problems can also cause or worsen vertigo.
• Motor vehicle accidents, falls or other types of traumas or illnesses can also be associated with vertigo especially if they cause head trauma.
• To diagnose the cause of vertigo, your health care provider will perform an examination, including a variety of positioning tests, to check if they will reproduce the sensation of motion. Other tests may also be necessary and will require a referral to medical specialists.

Treatment:

Uncomplicated cervicogenic vertigo can be treated and well managed by a chiropractor incorporating: mostly painless and effective soft-tissue and muscle work such as trigger point release or stretching, and/or the Epley. Additionally, spinal and associated joint manipulation and adjustment, physiotherapy modalities and/or low-level laser acupuncture may also be utilized depending on the physical examination and any radiological findings. The goal is to balance the biomechanics of the neck and associated soft-tissues in order to promote a more rapid and complete recovery of the damaged tissues and any abnormal postural mis-alignments.

For Benign Paroxysmal Positional Vertigo (BPPV), the Semmont’s Maneuver or Epley’s Maneuver can be utilized (see below).

The treatment used obviously depends on the cause. Don't rely totally on symptomatic relief such as taking tablets for this condition is not always the answer. That is why the chiropractor has to do a thorough consultation and examination when prospective patients  first come in for treatment. In some cases a referral to your physician, neurologist or an ear/nose/throat (ENT) specialist may be required for further assessments especially if any 'red flags' are presented (see below). But, the good news is that the most common causes respond well to conservative care.

Vertigo Red Flags That Requires Medical Care: 

By itself, vertigo is usually benign. However, if a patient experiences symptoms such as double vision, slurred speech, difficulty swallowing, numbness, nausea and/or unsteadiness when walking, (even if temporary), they should seek immediate emergency medical care.

Vertigo patients who present with the following signs should immediately go to the emergency room

• double visiondifficulty swallowing
• numbness
• headache
• fainting or collapse
• weakness
• nausea
• difficulty speaking such as slurred speech
• difficulty waking up or staying awake
• difficulty walking, even if temporary
• inappropriate actions
• difficulty controlling arms or legs
• abnormal eye movements
• patients experiencing progressive worsening of symptoms or dizziness accompanied with fever and/or infection should also see a medical health care provider.

TINNITUS: Research indicates that certain types of nutritional support may help tinnitus sufferers. Before embarking on taking nutritional supplements, check with your health care provider for their advice and approval!

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Vitamin B12 Sheathes Ear Nerves:

When it comes to nerves, vitamin B12 plays a special role. The body needs this nutrient to manufacture myelin, the fatty sheath that wraps around nerve fibers, insulating them and allowing them to conduct their electrical impulses normally.

A vitamin B12 deficiency can raise blood levels of homocysteine, an amino acid that is thought to be toxic to nerves. Low levels of B12 have been linked to a number of nervous system disorders, including memory loss, decreased reflexes, impaired touch, or pain perception--and, apparently, tinnitus and noise-induced hearing loss.

Researchers from the Institute for Noise Hazards Research and Evoked Potentials Laboratory at Chaim-Sheba Medical Center in Ramat Gan and from Tel Aviv University, both in Israel, looked at a group of 385 people with tinnitus and found that 36 to 47 percent suffered from vitamin B12 deficiency. All the people low in B12 received injections of 1,000 micrograms weekly for four to six months. At the end of that time, their hearing and tinnitus were evaluated. Fifty-four percent reported improvement in their tinnitus, and approximately one-fourth reported reductions in the measured loudness of their tinnitus, according to Joseph Attias, D.Sc., head of the institute and one of the study's main researchers.

 "Vitamin B12 deficiency is somehow associated with chronic tinnitus," says Dr. Attias. "Long-term exposure to noise may deplete body levels of B12 and so make the ears more vulnerable to noise-induced damage." Most of the people in this study had tinnitus for six years or longer.

 "It's possible that people who are treated earlier for vitamin B12 deficiency may have more improvement in their tinnitus than occurred in this study," says Dr. Attias. If you have tinnitus, and especially if you also have memory problems, ask your doctor to check your blood level of vitamin B12, he suggests.

Although most people get enough vitamin B12 from foods, absorption problems can cause shortages, especially in older people. Strict vegetarians, who eat no meats, dairy products, or eggs, are also at risk for deficiency, since B12 comes only from animal foods.

 If your doctor determines that you have absorption problems, you will need vitamin B12 shots for the rest of your life. If you do not have absorption problems, experts say that it is safe to take about 1,000 micrograms of B12 a day.

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Magnesium May Shield Sensitive Ears:

It is true that you will not find laboratory animals handling heavy artillery or using chain saws. But you can thank these creatures for another dietary recommendation for protecting ears: magnesium.

Magnesium-deficient lab animals exposed to noise have much more damage to the nerve cells in their cochleas than animals fed a diet adequate in magnesium, Dr. Attias says. What happens to these cells when the noise level gets too high? "The tiny hairs on these cells fuse or disappear, and they and their supporting cells eventually disintegrate, along with the nerve fibers going to these cells," explains Dr. Attias. Low levels of magnesium combined with noise exposure eventually depletes the cells' energy stores, leading to exhaustion, damage, and death of the inner ear cells. Low magnesium levels can also cause blood vessels, including the tiny arteries going to the inner ears, to constrict. (Remember, noise-induced vasospasm is thought to play a role in tinnitus.)

Human ears, even young, healthy, normal-hearing ones, can benefit from extra magnesium, Dr. Attias says. He found that Israeli soldiers who got an additional 167 milligrams of supplemental magnesium daily had less inner ear damage than soldiers getting placebos (blank look-alike pills). According to Dr. Attias, a more recent study showed that supplemental intake has this same protective effect against long-term noise exposure.

If you are faced with a noisy environment, you will want to make sure that you are getting the Daily Value of magnesium, which is 400 milligrams, Dr. Attias says. Most people fall short in that regard, with men getting about 329 milligrams a day and women averaging 207 milligrams a day. Green vegetables, whole grains, nuts, and beans are packed with magnesium. (If you are considering taking magnesium supplements, be sure to talk to your doctor first if you have heart or kidney problems.)

If your tinnitus includes a sensation of fullness in your ear and balance problems, experts recommend that you get adequate amounts of calcium and potassium as well. These additional symptoms could be a sign of Meniere’s Disease.

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Antioxidants May Help Spare Ears:

Tinnitus is sometimes caused by impaired blood flow to the ears, which can happen in two ways, Dr. Seidman says. First, the tiny artery leading to the inner ear can get clogged with cholesterol, causing a kind of stroke in the ear, Dr. Seidman explains. Second, loud noises can send this artery into spasm, reducing blood supply to the cochlea. In either case, an interrupted blood supply can lead to hearing problems.

That is where the antioxidant nutrients--vitamin C, vitamin E, beta-carotene, and others--come in. "Antioxidants work by helping to prevent oxygen-caused damage to cell membranes," Dr. Seidman explains.

Antioxidants also help keep arteries open and free of plaque buildup, experts say. Dr. Seidman and some other ear doctors suggest that you consider a smorgasbord of antioxidant nutrients: 400 international units of vitamin E daily, 250 milligrams of vitamin C twice daily, 50 to 200 micrograms of the mineral selenium daily and about 50,000 international units of beta-carotene twice daily. Doses of selenium exceeding one hundred micrograms daily can be toxic and should be taken only under medical supervision.

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Zinc Can Make a Difference:

Some parts of the body have much higher concentrations of certain vitamins and minerals than other parts. That is the case with the inner ear, which, like the retina of the eye, has a high concentration of zinc. That finding has led some doctors to speculate that zinc deficiency may play a role in inner ear problems such as tinnitus.

"We don't know much about how zinc works in the inner ear, but it's evident that the cochlea needs zinc to function properly," explains George E. Shambaugh, Jr., M.D., professor emeritus of otolarynology and head and neck surgery at Northwestern University Medical School in Chicago. 

"Animals fed a diet low in zinc partially lose the ability to hear, and apparently, even the kind of marginal zinc deficiency often seen in older people worsens the hearing loss associated with ear damage from noise or aging." Zinc is involved in a wide array of functions, including helping to maintain healthy cell membranes and protecting cells from oxygen-related damage.

Dr. Shambaugh estimates that about 25 percent of the people he sees with severe tinnitus are zinc deficient. Sometimes they also have poor appetite, hair loss, diminished taste or smell or skin problems. All these symptoms are related to zinc deficiency. For these people, he recommends supplemental zinc, along with a potent multivitamin/mineral that supplies other nutrients.

Although Dr. Shambaugh and other ear, nose and throat specialists may initially give large doses of zinc, up to 150 milligrams a day, it is important to take no more than about 15 milligrams a day without medical supervision. Doctors monitor blood levels of zinc when they prescribe higher amounts. That is because zinc can be toxic in large doses. Zinc also interferes with copper absorption, so if you are taking high doses of zinc, you may need to take supplemental copper (the ratio that is generally recommended is 1 milligram of copper for every 10 milligrams of zinc). Copper, too, can be toxic, so follow your doctor's advice on this.

The Daily Value for zinc is 15 milligrams. According to Dr. Shambaugh, few people get 10 to 15 milligrams a day in their diets, while people over age 75 rarely get as much as 7 milligrams a day. Look to meats and shellfish for zinc; cooked oysters, beef, crab, and lamb all offer good amounts.

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Vitamin A May Aid Hearing:

Like zinc, vitamin A is found in high concentrations in the cochlea. "All special sensory receptor cells, including the retina of the eye and the hair cells of the inner ear, depend upon vitamin A and zinc to function properly," Dr. Shambaugh says.

In one study, low blood levels of vitamin A were associated with decreased ability to hear. And in several studies, from 24 to 74 percent of people with tinnitus reported at least partial relief from vitamin A supplements.

"I recommend beta-carotene, which you can take without worrying about toxicity," Dr. Shambaugh says. (The body can use beta-carotene to make vitamin A.) He recommends taking 30 milligrams (about 50,000 international units) of beta-carotene twice a day.

Meniere's Disease is a disorder of the inner ear that causes severe dizziness (vertigo), ringing in the ears (tinnitus), hearing loss, and a feeling of fullness or congestion in the ear. Ménière’s disease usually affects only one ear. Ménière’s disease can develop at any age, but it is more likely to happen to adults between 40 and 60 years of age. Attacks of dizziness may come on suddenly or after a short period of tinnitus or muffled hearing. Some people will have single attacks of dizziness separated by long periods of time. Others may experience many attacks closer together over a number of days. Some people with Ménière’s disease have vertigo so extreme that they lose their balance and fall. These episodes are called “drop attacks.”

Benign Paroxysmal Positional Vertigo (BPPV) is one of the most common causes of vertigo and dizziness. 

BPPV means:

• Benign - a non-progressive condition;
• Paroxysmal - sudden and unpredictable in onset;
• Positional - episodes are caused by a change in head position;
• Vertigo - a sense of dizziness or spinning.

Benign Paroxysmal Positional Vertigo:

• About 65 percent of vertigo is diagnosed as Benign Paroxysmal Positional Vertigo (BPPV) that comes and goes based on head and neck position. When triggered, the dizziness can last a few seconds to a few minutes or even longer.
• Symptoms are commonly triggered by rising from sleep, tilting the head, rolling over in bed, looking up or sudden head motion. This type of vertigo is related to an inner ear problem and the most common cause is a sudden trauma (like a fall).
• BPPV is usually treated through the Epley maneuver—a procedure in which the patient is rapidly moved from lying on one side to lying on the other, to move the calcium debris to a less sensitive location in the inner ear.
• Studies show that up to 80 percent of patients recover after a single treatment with Epley maneuver. However, most BPPV cases respond to two to three treatments with Epley.
• Epley maneuver is contraindicated in patients with severe carotid stenosis, heart diseases and severe neck problems, such as cervical spondylosis with myelopathy or advanced rheumatoid arthritis.
• Even without treatment, BPPV tends to resolve in weeks or months and also has a tendency to recur.
• Vestibular rehabilitation exercises (called the Brandt-Daroff exercises) can also be performed at home to help treat BPPV.

BPPV is an inner ear condition that causes brief severe episodes of vertigo feeling like the room is spinning. While it can occur in children, the older you are the more likely it is that your dizziness is due to BPPV. About 50% of all dizziness in older patients is due to BPPV.

The inner ear is responsible for balance and motion sense of the head. Within the labyrinth of the inner ear are floating calcium carbonate crystals called otoliths (otoconia, or “ear rocks”). In BPPV, the otoliths are dislodged from their normal position and migrate into the semicircular canals. The semicircular canals are oriented at roughly ninety degrees to each others. They are filled with fluid called endolymph and also have sensory receptors that are stimulated during head movement to provide motion sense and balance. In BPPV, crystals in the semicircular canals are dislodged and stimulate sensory nerve receptors adversely giving rise to feelings of motion (vertigo) when there are none.

What are the causes of BPPV?

Generally about 20% of all cases of dizziness are due to BPPV and about 50% of all dizziness in older patients is also due to BPPV. Other common causes include acute vestibular neuronitis or labyrinthitis. In half of all cases, BPPV is called "idiopathic," which means it occurs for no known reason.

The most common cause in the under 50's is head trauma and whiplash injuries, which may eventually develop into or aggravate vertebral degenerative disc disease (osteoarthritis) of the neck (cervical spine) vertebrae. In older people, the most common cause is degeneration of the vestibular system of the inner ear and BPPV becomes much more common with advancing age.

There are other, more serious, causes of vertigo such as:

1. A head injury

2. Due to the aging process
3. Minor strokes
4. A severe cold or virus
5. Tumours
6. Use of ototoxic medications, e.g. gentamicin
7. Neurological diseases such as MS.

With these conditions there are other symptoms present as well and they are normally picked up in the chiropractic and neurological examination, sometimes requiring a referral for medical follow up.

A firm diagnosis and the right treatment can help you get rid of this disabling condition, and quickly. BPPV frequently goes undiagnosed and is treated symptomatically with medically prescribed drugs such as Stemetil and Compazine (prochlorperazine), a sedative, which can make you feel very tired. If you are prescribed this drug you should not operate machinery or drive, and, it can have many other side-effects.

Symptoms of BPPV can include the following:

1. Severe but brief episodes of dizziness, without hearing loss or ringing in the ears

2. Feeling light-headed

3. A feeling of imbalance and nausea.

The symptoms usually start suddenly and often when waking from sleep. Episodes are triggered by changes in the position of the head such as getting out of bed or turning over in bed, tipping your head back to look up and certain Yoga or Pilates positions such as the 'down dog'.

Testing to Diagnose BPPV:

Chiropractors are able to diagnosis this condition after taking a full case history and performing a physical and neurological examination. Specific tests, such as the hallmark 'Dix-Hallpike Maneuver', if positive, is used to differentiate peripheral from central vertigo. This test will reliably provoke the vertigo and cause rotary or horizontal nystagmus (involuntary eye movement). It also determines the side of ear involvement. Click here to view the Dix-Hallpike Maneuver to test and diagnose BPPV dizziness.

IMPORTANT: Please note that feeling dizzy in the absence of Nystagmus is not considered diagnostic for BPPV. Eye twitching MUST be present for BPPV to be diagnosed.

Treatment of BPPV:

BPPV can be corrected using either Semmont’s Maneuver or Epley’s Maneuver. These maneuvers are simple and well tolerated in the majority of patients.

The chiropractor will assist the patient to slowly move their body, head and neck into specific and appropriate 're-positioning' positions depending on what has previously been found in the assessment. Using gravity, the floating calcium carbonate crystals (otoliths) in the endolymph of the semicircular canals that stimulate the sensory nerve receptors are encouraged to move away into the correct location in an area of the inner ear where they will, hopefully, cause no further symptoms of vertigo.

Following the procedure, the patient is instructed to avoid sudden movements and to sleep for 2 nights in a recumbent position. This procedure has a 90% success rate and often only one treatment is required. If the dizziness returns, the procedure is repeated.

If chiropractic care requires adjunctive therapy, then the chiropractor may also recommend a medical referral to a qualified physiotherapist (PT) or an occupational therapist (OT) to provide an assessment and develop an individualized treatment plan called Vestibular Rehabilitation Therapy (VRT) (Vestibular Physiotherapy) that includes specific head, body, and eye exercises to be performed both in the therapy setting and at home... Click here to download the "Vestibular Rehabilitation Therapy (VRT)" publication.

1 - Click here to watch a demonstration of the standard 'Epley' Maneuver to treat Posterior Canal BPPV for patients with 'rotatory/torsional' nystagmus.

2 - Click here to watch a demonstration of the Epley Maneuver called the 'Lempert (BBQ)' Maneuver to treat Lateral Canal BPPV for patients with 'lateral/horizontal' nystagmus.

3 - Click here to watch a demonstration of the Epley Maneuver called the 'Deep Head-Hanging' Maneuver to treat Superior Canal BPPV for patients with 'vertical' nystagmus.

The treatment is very effective and within 3-4 treatments, 80% are symptom free. The symptoms can recur and research shows a relatively low recurrence rate of about 15 percent per year.

Nutrition and Stress Reduction:

• Alcohol, nicotine, fried foods and excessive salt intake are potential sources of trouble for patients of vertigo.
• Vincopectine, vitamin B6 and ginkgo biloba may be helpful in reducing vertigo. 
• Chromium may be helpful in patients whose vertigo is caused by a blood sugar imbalance.
• Physical exercise and meditation, adequate sleep and other stress reduction techniques can all help contribute to recovery from vertigo and should be a part of the treatment regimen.
  
• Your doctor of chiropractic can help create an appropriate exercise program for you and counsel you regarding healthy lifestyle and stress relief. 

Click here for link to vertigo and pain caused by neck movement and problems with the spinal neck vertebrae.
Click here for link and video: "Colorado Doctor Discovered Natural Way To Treat Common Vertigo".
Click here for Vertigo BPPV Treatment with Simple Self-Directed Exercise.
Click here to read a well written booklet that provides information on dizziness and balance problems.
Click here for an important systematic review regarding "Manual therapy with and without vestibular rehabilitation for cervicogenic dizziness."
Click here for a case report on the effectiveness of chiropractic management of a patient suffering with BPPV.

Chiropractic treatment might not be the first thing you think of if you have dizziness, but the maneuvers and treatment used is the same as you would have if you go to medical clinicians who specialize in these conditions.

Chiropractic is not suited for all types of dizziness, but if we can't help you we will refer you back to your medical physician for further testing and a possible referral to a neurologist.

Source: The Mystery of Vertigo - By Nataliya Schetchikova, PhD - The American Chiropractic Association

If you have any of the above symptoms and require further information,
please call Dr. Pisarek at (416) 633-3000 for an appointment
to determine if your condition and it's treatment
falls within the scope of Chiropractic care.