Date: Tue, 20 May 1997 19:59:29 +0100 From: rbartz@mhv.net (Rick Bartz) Subject: Vertigo Dear Sci-listers; I have a patient, 74 yo male, presenting with daily headaches, and occasional severe, disabling attacks of objective vertigo. He reports feeling light-headed with a loss of balance and nausea. There is no vomiting, falling to the side, auditory, nor visual disturbances. He must withdraw to bed to sleep off the duration of the attack. Attacks started six months ago, and were originally 12 to 18 hrs in length, hospitalized, and occuring once every two months, but now vertigo attacks are of progressively shorter duration, but occuring more frequently, once every two weeks or more. The patient cannot lie in the supine position and has a positive George's Test. All radicular, posterior column, and cerebellar tests are negative. He has globally reduced cervical ROM. Pt. has been to two ENT specialists and a neurologist, who report all neurological and vascular tests negative. MRI of the brain is normal and cervical x-rays show moderate degenerative changes of disks and facets from C3-C5. The MD's dx is viral infection(?!) of the inner ear, and patient takes Antevert 25 mg, tid. Headaches are 60% better, as reported objectively by the patient, since my treatment started 3 weeks ago. I am reluctant to use diversified adjustments. I have used muscle stim, myfacial release and activator adjustments of the cervical vertebrae and upper thoracic musculature, all in the seated position. I am proficient in SOT cranial, but lying the patient supine induces vertigo before my cranial adjustments are, what I would call, effective. Any suggestions, techniques, studies, or theories on chiropractic and neurological pathways involved in vertigo would be appreciated either on the list, or privately. Rick Bartz, DC Bearsville, NY ----------------------- To: rbartz@mhv.net Date: Tue, 20 May 1997 23:21:12 -0400 Subject: Re: Vertigo From: docdaniel@juno.com (Daniel A. Shaye-Pickell) Interesting. I have a few questions and thoughts which may or may not help: 1. Is the vertigo affected by closing the eyes, or is that not a feature? 2. I'm wondering about otoliths, which traditionally aggravate vertigo in a particular posture. There is a technique for mobilizing these if they exist. See: Journal of Otolaryngology, 1992, "Canalith Repositioning Procedure." (I realize that's an incomplete reference, but it's all I have). Also, Robert Humphreys, M.S. (physiology), D.C. suggests figs to alkalize the body in order to bring the Ca into solution. Does it work? I haven't a clue. But let me know. 3. I've heard some suggest that habituation to the vertigo-producing postures may have some value in desensitizing the CNS' response. 4. Acoustic neuroma: MRI ruled out? Also, lack of auditory changes seems to lean against this. But, I don't like the increasing symptoms. 5. Any other medications? 6. Cervicogenic vertigo: Does varying stress on the cervical spine aggravate the vertigo? If we turn the patient suddenly (as on a swivel chair, a la Fitz-Ritson) without turning the neck, do the symptoms come on, or not? Is your theory that this is a vascular problem, as opposed to cervicogenic vertigo or a vestibulocochlear problem? Tough case. But I'm rapidly learning that they are ALL unique. Let me know the outcome. Dr. Daniel A. Shaye-Pickell, Chiropractic Physician Performance Chiropractic, LLC (R) ----------------------- Date: Tue, 20 May 1997 23:42:20 -0500 (CDT) From: Mike Carstensen Subject: Re: Vertigo At 07:59 PM 5/20/97 +0100, you wrote: >I have a patient, 74 yo male, presenting with daily headaches .. The first thing that comes to mind is this: Is it true vertigo? Does the patient describe a sensation of spinning or one of dizziness? I could not distinguish that definitively from the above paragraph but it sounds like it may actually be vertigo. Have you performed Fitz-Ritson's test to help determine whether or not the symptoms are cervicogenic or vestibular? Check out: Douglas, F. The Dizzy Patient: Strategic Approach to History, Examination, Diagnosis and Treatment. Chiropractic Technique 1993; Vol(5), No. (1), February. Dr. Michael Carstensen INMOTION Health Center Richmond Heights, Missouri docmike@i1.net ------------------------------------ Date: Wed, 21 May 1997 09:13:05 -0500 From: "Noel A. Taylor" Subject: Re: Vertigo Rick, do you know at what degree of rotation from standing toward supine the vertigo is induced? I've been able to do SOT Cranial work on patients who cannot obtain the supine position by treating them in a "Stratolounger." However, your description brings to immediate mind the inner ear condition where a small piece of the internal cochlear mechanism has become a free body and occasionally lodges upon receptors of the cochlea, producing exactly the symptoms you describe. Some call this Meinere's Disease. Cervical extension is often very distressing for these patients, as is the supine position. Standard of care for such a condition is a "fatiguing" protocol where the patient is trained to induce deliberately the symptoms by moving repeatedly into a posture which just begins to trigger the effect, until it no longer does, and then moving farther into that posture, repeating the fatiguing. Such treatment often takes from weeks to months to be effective, and must be retained as a reduced schedule maintenance protocol for years, perhaps lifetime. Nevertheless, I would recommend that you do some "rule-out" work before you assume Meinere's. First is the possibility that Georges is positive due to severe proprioceptive c-spine disturbance. When you say "Georges" are you referring to the functional maneuvers only or to the entire history/BP/auscultation test? If just the fx maneuvers, I frequently find that patients with an initial positive Georges fx maneuver will test negative two minutes later after multiple full cervical passive ROM is performed. This sequence of findings rules out VBAI as primary in the initial fx maneuver findings, and reveals cervical spine proprioceptive dysfunction as primary. (A review of the mechanisms involved here can be seen in Guyton's treatment of the vestibolo-occular reflex and its integration with c-spine proprioceptive feedback.) You may still decide that there are other reasons not to perform diversified-type adjusting on the c-spine, but at least you won't have pseudo-positive George's functional maneuvers to muddy the waters. Second, I would do complete motion palpation of the cervical spine to determine where any segmental dysfunctions may reside. This can be accomplished seated or prone, perhaps avoiding the problems of symptom aggravation. SOT cervical stairstep protocol can serve well here, and can be effectively performed in the Stratolounger as well. This protocol also serves as an effective treatment of c-spine restrictions and fixations, should you chose not to employ HVLA techniques. As an alternate course, if you confirm segmental dysfunction but are not comfortble using Gonstead, diversified, or SOT techniques on this patient, would be to refer him to a Thompson practicioner who has the equipment necessary to perform the limited motion prone c-spine adjusting possible in that technique. (What's his c-spine bone density status?) Finally, the MD "finding" of "viral infection" must be based upon some clinical indication of inflammation. As you are trained in SOT Cranial work, I direct your attention to "Ventricular Bulb Technique" as described in DeJarnette's 1979-80 _Cranial Technique_ text, and recommend evaluation of the ranges of motion of the occipital bone during all phases of cerebrospinal respiration. In my experience, and in DeJarnette's review, this very simple technique, when appropriately applied, addresses a host of "inflammation" problems. You may or may not find it appropriate on this specific patient. Again, such treatment is possible with assistance seated, and is easy in the Stratolounger. Best wishes! Apparently your STM/Activator combination has served some of his presentation well already. Keep on pluggin'....(GRIN) --Noel ------------------- Date: Wed, 21 May 1997 11:13:34 -0400 (EDT) Subject: Re: Vertigo Reply-To: RLBMagic@aol.com <.. <> Certainly sounds like it belongs on the DDx, but who knows? You could certainly use supplementation to boost the immune system, the risk/bennefit ratio being extremely low. <> If you have a high-low table try lowering him until just before the vertigo sets in, and see if it's low enough to work with. An Upledger cranial worker can work with the patient in any position. Also, make sure there's good vascular drainage in the neck following your cranial work, such as STM with the anterior scalenes. (And, of course, when you work the ant. scal. check the 1st ribs.) Give it time. If there has been nerve damage, it will take time to heal, and it sounds like you're making some progress. Just a few suggestions off the cuff. Richard Berman, D.C. ----------------------- Date: Thu, 22 May 1997 07:19:39 -0800 From: robetw9@IDT.NET (Rob & Wendy Ward) Subject: Re: Vertigo Noel wrote: >However, your description brings to immediate mind the inner ear condition >where a small piece of the internal cochlear mechanism has become a free >body and occasionally lodges upon receptors of the cochlea, producing >exactly the symptoms you describe. Some call this Meinere's Disease. The condition you describe is called benign positional vertigo (BPV), and the loose body is called an otolith. It can occur at almost any age. Meniere's disease, in contrast, is caused by an overproduction of endolymph within the vestibulocochlear system, causing progressive vertigo and hearing loss, and generally eventually resulting in deafness. It is most common in older men, and does not have the positional dependency described for the patient in this thread. >Cervical extension is often very distressing for these patients, as is the >supine position. Standard of care for such a condition is a "fatiguing" >protocol where the patient is trained to induce deliberately the symptoms by >moving repeatedly into a posture which just begins to trigger the effect, >until it no longer does, and then moving farther into that posture, >repeating the fatiguing. Such treatment often takes from weeks to months to >be effective, and must be retained as a reduced schedule maintenance >protocol for years, perhaps lifetime. Right on. >Nevertheless, I would recommend that you do some "rule-out" work before you >assume Meinere's. First is the possibility that Georges is positive due to >severe proprioceptive c-spine disturbance. When you say "Georges" are you >referring to the functional maneuvers only or to the entire >history/BP/auscultation test? If just the fx maneuvers, I frequently find >that patients with an initial positive Georges fx maneuver will test >negative two minutes later after multiple full cervical passive ROM is >performed. This sequence of findings rules out VBAI as primary in the >initial fx maneuver findings, and reveals cervical spine proprioceptive >dysfunction as primary. (A review of the mechanisms involved here can be >seen in Guyton's treatment of the vestibolo-occular reflex and its >integration with c-spine proprioceptive feedback.) You may still decide >that there are other reasons not to perform diversified-type adjusting on >the c-spine, but at least you won't have pseudo-positive George's functional >maneuvers to muddy the waters. Also right on. I have several times found a positive Maigne's or DeKlyne's test (even once on myself) that resolved completely following the "contraindicated" cervical adjustment. >Finally, the MD "finding" of "viral infection" must be based upon some >clinical indication of inflammation. This is not necessarily true. Many practitioners are either afraid or unable to utter the ominous phrase "I don't know", and will forward a diagnosis in spite of an absence of clinical data, and sometimes in the presence of scant data that actually rules out the hypothesized diagnosis. Viral infections of various types are commonly given as diagnoses even though no laboratory testing to detect such infection has been performed. Rob Ward, DC -------------------- Date: Fri, 23 May 97 13:07:47 UT From: "RD " Subject: RE: Vertigo Here is an excelant reference for the DDx of the "DIZZY" patient. It has a large guided flow chart. "A diagnostic algorithm for the dizzy patient" by David J. Schimp, D.C. Chiropractic Techique Vol 6, No4 November 1994, pp 123-137 ****************************** Date: Tue, 24 Feb 1998 05:49:32 -0800 From: Dr Warren Jahn Organization: Chiropractic Orthopaedics & Sport Injury To: chirosci-list@silcom.com Subject: FYI Reply-To: Dr Warren Jahn http://www.medscape.com/Medscape/public/MP/98/0220.html#11> - Dizziness: A Diagnostic Puzzle ---------------------------------------------------------- A careful history and physical examination are the cornerstone for establishing a diagnosis, and the key to avoiding unreasonable, expensive, and uncomfortable tests. [Hospital Medicine 34(1): 39-44, 1998] -- Warren T. Jahn DC MPS FACO DACBSP Roswell, GA ***************************