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Cervical Degeneration and Cervical Vertigo

Cervical vertigo is a controversial entity in the world of balance and vestibular disorders. It has generally been a diagnosis of exclusion when a patient is feeling dizzy but has no diagnosable pathology in the inner ear or brain.

The reality is that problems in the cervical spine are commonly linked to feelings of imbalance and disequilibrium. Cervical spine problems are rarely tied to the spinning rotational vertigo of someone having inner ear pathology. Most people with cervical “vertigo” really have which can include feelings of being really off balance, shaky, or a tilt like feeling of motion.

A 2018 study looked at how a degenerative problem in the neck can be associated with a diagnosis of cervical vertigo:

Mechanoreceptors in Diseased Cervical Intervertebral Disc and Vertigo

The study looked at patients with neck and arm pain related to cervical disc problems presenting for surgery. The patients were divided into patients with and without a complaint of vertigo. The patients with vertigo were examined to rule out other causes of vertigo like vestibular neuritis, benign positional vertigo, or stroke.

The research team examined the discs from patients with vertigo, without vertigo, and a control group of cadavers with no disc degeneration. The findings were really interesting.

In patients with vertigo, there are large increases in mechanical receptors in the degenerated discs compared to the patients without vertigo, and to the control group. These Ruffini Corpuscles help detect movement and position from your joints and muscles to help tell your brain what your joint is doing in space. Free nerve fibers are responsible for transmission of stimuli usually associated with pain. You can see the distribution below:

Patients with vertigo had significantly more Ruffini Corpuscles in their degenerated discs than the non-vertigo and control group. What does this mean for dizzy patients?
Patients with vertigo had significantly more Ruffini Corpuscles in their degenerated discs than the non-vertigo and control group. What does this mean for dizzy patients?
The data from the above chart in bar graph form showing increased receptors in the vertigo patients.

As expected, the patients with neck pain only, and neck pain with vertigo have a similar increases of free nerve fibers compared to controls. That’s probably why their neck is hurting.

However, a big reason why this study is interesting is because many people in the world of rehab and manual medicine would usually associate dizziness with a decrease in mechanical receptors in their spine, not an increase.

So what gives?

We don’t know exactly what this means, but it’s possible that increased density of these receptors may be transmitting excessive or erroneous information to the brain about the joint position.

The same group did a follow up study after they had performed disc surgeries on these patients. You can see the link to the study below:

Cervical Intervertebral Disc Degeneration Contributes to Dizziness: A Clinical and Immunohistochemical Study

During the study, they performed surgery on 50+ patients and 25 patients refused the surgery and received basic physical therapy and cervical collar recommendations. You can see the results below:

Comparison of patients with cervical dizziness and neck pain getting surgery vs routine physical therapy and neck bracing.

You can see that the patients who had the neck surgery showed clear and long lasting improvements in both neck pain and dizziness compared to the conservative group which implied that the degenerated disc was the probable source of bad sensory information to the brain.

So Is Surgery the Right Answer for Cervical Dizziness?

Maybe for some cases. If you have radiating arm pain with weakness tied to a badly herniated disc, then surgery might be able to help resolve both complaints, but there’s still a lot of research that needs to be done. Surgery is a BIG deal, and generally reserve that for really bad herniation cases with clear signs of neurological deficit like weakness, loss of reflexes, and atrophy of muscle.

The good news is there are a lot of ways to address cervical dizziness beyond routine physical therapy, and they have really great outcomes. One method is by improving the curve in the neck. A randomized trial of curve based rehab compared to routine physical therapy showed significant improvements in neck pain and dizziness at 1 year.

You can read some more about cervical curves and dizziness at this link:

Working on your curves: Long term outcomes from fixing military necks

A randomized clinical trial of cervical curve rehab on cervical dizziness

There’s also numerous cases of cervical dizziness that have no signs of degeneration in their spine. This is especially prevalent in patients with dizziness after whiplash and head injury in young athletes. These patients seem to do well when we focus on the upper neck where the injury is likely to affect the ligaments of the craniocervical junction.

Comparison of mulligan sustained natural apophyseal glides and maitland mobilizations for treatment of cervicogenic dizziness: a randomized controlled trial.

Long story short, degeneration of the cervical spine doesn’t have to be a sentencing for dizziness. It’s a risk factor, but it can be modified with the application of effective conservative interventions for the neck.

Concussion and Eye Movement Series Part 2: Smooth Pursuits

Smooth pursuit eye movements are the ones we use to follow a moving object without moving our heads.

We take it for granted how simple this is, but this eye movement requires the coordination of several brain regions including the parietal lobe, temporal lobe, cerebellum, and multiple brain stem nuclei.

Image result for smooth pursuits neural substrates

Here’s a ridiculously complex graphic about the brain regions involved in smooth pursuits. It’s insane what goes on in the brain to accomplish such a seemingly simple task. A concussion can disrupt any part of this pathway, or multiple parts depending on the nature of the injury.

It requires us to:

  • Predict an object’s velocity – Correct for quick changes in direction
  • Maintain focus and attention
  • Ignore new and interesting background stimuli

After we hit our heads, any one of these areas can be affected which means different elements of smooth pursuit can become compromised.

Brain injuries can cause our pursuits to become slow, get pulled off target, delay reaction time, or even ignore parts of your visual field.

This can cause problems for athletes who need elite visual tracking abilities like baseball players, wide receivers, and hockey players. But some important notes:

  • Smooth pursuit deficits can be completely asymptomtic
  • Having poor pursuits isn’t useful diagnostically because many problems including aging can cause bad pursuits
  • Smooth pursuit testing needs to be taken on the context of other exam findings to localize the problem in the brain and determine the best method of rehabilitation

While it doesn’t tell us much diagnostically, it can be used as a metric to see how well your brain is responding to #neurorehabilitation.

Concussion and Eye Movement Series Part 1: Anti-Saccades

Eye movements have become an important diagnostic for patients with neurological disease and dysfunction. It’s one of the reasons we have invested into using extremely sophisticated eye tracking technology so that we can asses and manage patients effectively with traumatic brain injuries.

This will be the first in a series of posts about eye movements that are commonly affected with concussion. The first eye movement we’ll discuss is called anti-saccades.

What’s A Saccade?

In order to know what an anti-saccade is, we have to know what a regular saccade is. A saccade is a fast eye movement that takes your eyes from one target to another. Saccades are the eye movements we use to explore the world around us. They are also eye movements that react very quickly to new things in our environment. These can be a movement in the background, a flashing light, a loud noise, or a touch on our skin.

When we perceive there’s something in our environment that needs our attention, we use saccades almost like a reflex to direct our brain’s attention toward that new stimulus.

What’s an Anti-Saccade

An anti-saccade is a concept developed to see if someone can consciously inhibit a desire to look at something new. During an anti-saccade, we would have you fixate on a central target, and when a new target comes up, we ask you to move your eyes in a spot opposite to where the new target appeared.

The anti-saccade test


Antisaccades require our brain 🧠 to ignore a new stimulus and to create a plan to move the eyes 👀 to a mirror location.

This task requires higher level brain activity because our brains are wired to look at new stimuli. Specifically it requires a functioning prefrontal cortex (PFC).

In patients with concussion, their ability to perform Anti-saccades is compromised where they make frequent eye movements towards the new target, or they take a long time to move their eyes in the opposite direction. This indicates problems with a function called response inhibition. It’s the ability for our brain to stop doing something we don’t want it to do.

This requires a part of our brain called the pre-frontal cortex. Specifically, the dorsolateral prefrontal cortex. We’ll just call it the PFC for short. The PFC is what allows us to inhibit a desire to do something that may be inappropriate.

We need our PFC to stop ourselves from making inappropriate reactions. It’s one of the main differences between an adult brain and a child’s brain is that our PFC keeps us from having meltdowns when something goes wrong.

Parents of toddlers, you guys know what I’m talking about.


So when we take a hit to the head and our PFC goes down, we can have responses that aren’t appropriate. This might mean an emotional outburst, or problems controlling wreckless behavior like uncontrolled gambling. A viable PFC is critical for that and for keeping our bodies from over reacting to stress.

This provides us a meaningful way to assess PFC activity and gives us an way to improve PFC activity using eye movement therapies.

Not only can anti-saccades be used to assess the functionality of someone’s PFC. It can play a role in helping someone rehabilitate their PFC or other aspects of the brain connected to it.

New Research Shows Concussion + Neck Injury = Longer Recovery

If you’re a reader of our blog, then you’re aware of our stance that an injury strong enough to concuss is strong enough to also injure the neck. You can read some of our thoughts on this subject here:

2 Reasons Why Your Concussion Symptoms Aren’t Going Away

Head Injury, Chronic Dizziness, Concentration Problems, and the Atlas – A Case Study

What a 10 mph car accident does to the neck

You can find a lot more by using the search tool on the website, but that should get you started.

 After years of research, we now know that injuries to the neck can mimic symptoms seen in concussion. This is a big reason why patients with chronic whiplash look really similar to patients with post-concussion syndrome when you’re just looking at symptoms alone [source]. However, many clinicians have suspected that when patients have both a neck injury and a brain injury, that it can take longer for the patient to recover and return to sport.

A study published in the Journal of Head Trauma Rehabilitation is helping to shed light on this concept. THe study looked at patients in a multidisciplinary pediatric concussion clinic with sports related concussion. A total of 246 patients were included and were assessed for neck pain, headache, dizziness, and abnormal cervical spine exam findings. Out of the 246 patients with concussion, 80 met the criteria for a neck injury.

When reviewing the data, the authors found that patients with a neck injury took an average of 28.5 days to make a clinical recovery compared to 17 days for the patients who only showed physiologic brain injury alone. Patients with neck injury were also almost 4 times more likely to experience delayed recovery (longer than 4 weeks) from their symptoms.

So just to summarize, if you have a neck injury + concussion:

  • It will take on average 10 days longer to make a clinical recovery than a concussion alone
  • You are 4 times more likely to have symptoms beyond 30 days than a concussion alone

So you might be saying….well…maybe some of these neck injuries were really serious ones. Like the ones you might see where people have to wear a neck brace and get carted off the field. Obviously people with severe neck and spinal cord injuries can drastically skew the number of days it takes for people to recover and some may not recover at all.

The authors actually accounted for these types of injuries. One patient had a compression fracture and 5 patients had spinal cord injury or cord neuropraxia. All of these patients were taken out of the data analysis. So that leaves us with patients with a neck injury, but an injury that compromises the spinal cord.

Protect the Neck

The role of the neck has become a growing area of research in the field of head trauma. One study looking at the relationship between neck strength and risk for concussion showed that for every pound of increase in neck strength, there was a 5% reduction in risk of concussion. Another study shows a rehabilitation program that includes treating the neck in patients with post-concussion symptoms can accelerate a patients return to normal activity.

The neck is a neurologically important and inherently mobile area that can be prone to injury. When it is injured, people with a combination of brain and neck injuries may have higher levels of sensitivity than patients with more routine neck pain. That means that people who suffer concussions and neck injuries may benefit from more precise and gentle care than approaches that take a more aggressive style of treatment.

 

What are the risk factors for poor outcomes after a concussion?

When patients suffer a concussion, the vast majority of patients will have symptoms for 10 days or less. About 10-15% of concussed patients will develop persistent symptoms and be diagnosed with post-concussion syndrome.

Thanks to an explosion in concussion research in the last 20 years, we know a lot more about these head injuries than we have in the past. While we don’t know the exact physical reasons why some people are more likely to suffer from post-concussion syndrome, we do know some specific risk factors for people developing persistent symptoms.

Here’s a short but important list of factors that may make a young athlete more susceptible to chronic concussion symptoms:

  1. Patients with a history of migraine headache
  2. Patients with a history bipolar or anxiety disorder
  3. Patients with a family history of bipolar or anxiety disorder
  4. Patients with a previous concussion

There’s a few interesting things to take away from this:

  • Having a history of migraine likely means that your nervous system will be more vulnerable to the headache and nausea experienced with concussion symptoms. It may also signal that you have a sensitivity in your neck to issues that may stimulate the headache process and can be worsened by head trauma.
  • The first is that mental health seems to be a major player in the future expression of post-concussive symptoms like headache and dizziness. It shows us the power that mental health can have on physical health problems.
  • There’s no association with the severity of the concussion or losing consciousness. While a more severe hit to the head or getting knocked out seem like they would predict worse recovery, the data suggests that it doesn’t play a significant role in the development of persistent symptoms.
  • A lot of people get their physical symptoms treated for post concussion symptoms by a variety of providers, but a lot of people ignore their psychological and cognitive treatments. Having someone that can help manage their anxiety appropriately and use cognitive behavioral interventions can help many patients benefit from their physical symptoms.

Don’t Forget: Health Is A 3 Legged Stool

It’s easy to think about health in terms of physical ailments, but your overall well being is dependent on physical, mental, and emotional health. There’s a reason why people with depression and anxiety have worse outcomes for every physical ailment that exists. If you have a poor mental and emotional outlook, your brain simply doesn’t mobilize it’s repairing and recuperative resources as effectively.

In the world of concussion we often talk about getting the right care for concussions linking it to cervical spine problems, vestibular problems, or brain problems. What we sometimes forget is that some of our susceptibility to illness is related to our belief in the fragility or resilience of our bodies. Let’s restore faith in the strength of our bodies and make ourselves more robust healing machines.

Cracking the Code on Lightheaded Dizziness

When people say that they feel dizzy, most people, even healthcare providers usually think that you’re talking about the room spinning sensation of vertigo. However, there are thousands of people around the country describe themselves as having dizziness but don’t have the characteristic sensation of vertigo. Many patients may describe their dizziness as a rocking, swaying, floating, or disoriented feeling. More than anything, people with dizziness have a feeling of being out of sorts if it’s not specifically related to vertigo.

In this article, we are going to breakdown a specific and very common feeling that people associate with dizziness. We are going to talk about lightheaded dizziness.

Orthostatic Intolerance – a blood flow issue

Most people have had a feeling of light headedness at some point in their life. It’s most commonly felt when people go from laying down to standing too quickly. Your head feels funny and you might feel your vision get dark for a moment. After a few seconds, the feeling passes and you probably won’t even think twice about it.

This sensation of feeling light headed on standing is called orthostatic hypotension or orthostatic intolerance.These are terms used to describe the fact that when you change positions, your blood pressure didn’t meet the brain’s demand for blood in that moment in time.

Your brain is a greedy organ when it comes to blood flow. Although it only makes up about 2-3% of the body’s total mass, the brain hogs about 20% of the body’s blood flow. Your blood pressure is not just a marker for the health of your heart, but the purpose of a tightly regulated blood pressure is to make sure that your brain is getting that 20% blood flow at all times. 

While people generally think of their heart as the main controller of blood pressure, it is actually your nervous system that keeps it tightly regulated. It’s so regulated, that in the moments right before you stand (when the idea of standing was just a thought), your brain is sending messages to your muscles and arteries to tighten up so it can keep your blood pressure constant when you are changing postures.

Pretty neat right?

While most people can have moments of lightheadedness like this from time to time, it usually goes away on its own. However, some people feel this sensation on a regular basis. It’s been estimated that anywhere between 4% young adults and 30% of older adults experience orthostatic intolerance. About 42% of people with a complaint of dizziness have a complaint of light headed dizziness related to standing. [Source]

Whether you feel like you’re  spinning, rocking, or light headed, a persistent feeling of dizziness can lead to feelings of anxiety and depression because of the impact on your daily life activities. Orthostatic hypotension is also associated with increased incidence of cardiovascular events and overall mortality, especially in the aging population where feinting and dizziness can lead to falls

Why Does Orthostatic Intolerance Happen?

So far, research has shown that the light headed feeling from orthostatic intolerance is a blood flow issue in the brain. We also know that the autonomic nervous system is a major role player in this problem as many patients with this form of dizziness will have abnormal findings on head upright table tilt testing as well as abnormal blood pressure findings when using a valsava maneuver. [Source]

For many of these cases, there is a problem in the regulation of the sympathetic or parasympathetic nervous system. This gets further complicated by the fact that people who experience orthostatic hypotension may have the same symptoms, but the neurological mechanism that is causing the symptoms are different. [Source]. In general terms, the sympathetic nervous system may have problems constricting your arteries on standing, or the parasympathetic system may have difficulties in regulating your cardiac output. That’s why many patients with orthostatic issues may get evidence-based treatment for the condition.

How Is It Treated?

This part is difficult, because unless you’re in an area that does specialized autonomic laboratories, many people don’t even know this condition exists. Many people get misdiagnosed with vertigo. Many others will just have their condition brushed off.

If you’re lucky enough to have someone that understands orthostatic issues, then you will likely be managed with a regiment of blood pressure medication and IV’s to help keep your blood pressure from tanking. This gets complicated if a patient has HYPERtension when they lie down which is obviously problematic to give therapies that will non-specifically increase your blood pressure.

A Neurological Approach

While many doctors are concerned with blood pressure numbers in of themselves, from a chiropractic perspective we ask why the body is having an abnormal autonomic response to changes in posture. This is particularly important when we are thinking about the head.

When the head and neck shift, it can disrupt normal proprioception into the brainstem and have wide ranging effects of the autonomic nervous system. Excessive twisting or rotation of the Atlas vertebrae may also affect the jugular vein and how blood flow returns to the heart leading to problems with the vagus nerve and cardiac output.

We have also seen patients with dysautonomia have small disturbances in the function of their vestibular system. In some cases patients with orthostatic hypotension can experience vertigo, but in many cases it simply makes head and eye movement far less efficient.

When we put this all together, we have found that a cervical-vestibular approach has the potential to create important improvements in the autonomic nervous system which can help patients overcome their poor relationship with gravity.

Tell us about your dizziness

Dizziness: Misdiagnosed and Mistreated

Dizziness: Misdiagnosed and Mistreated

 

Dizziness is Hard to Diagnose

When people have dizziness as a complaint, it can be one of the most commonly misdiagnosed and mistreated conditions around. The challenge is that dizziness is a symptom that can be associated with lots of different conditions. Here’s a short list of conditions associated with dizziness:

Primary dizziness: Dizziness as a primary disease entity

  • Positional vertigo (BPPV)
  • Meniere’s disease

Secondary dizziness: Dizziness as a result of another problem

  • Stroke
  • Migraine
  • Concussion
  • Tumors
  • Medications

On top of that, dizziness means something different to different people. Does your dizziness feel like spinning? Rocking? Feeling off balance? Light headedness? Sometimes the feeling of dizziness can be hard to describe because you just feel disoriented and lost in space.

All of these factors are important to help a doctor get the right diagnosis.

It means that a doctor has to take a good health history, perform the right bedside tests, and order the appropriate diagnostic testing to find out the cause of your dizziness. Without knowing what’s causing this feeling, then administering the right treatment can be a lucky guess at best, or make you more dizzy at worst.

It’s no wonder that people who have chronic vertigo and other balance issues often see their primary care doctor, neurologist, ENT, physical therapist, acupuncturist, and more looking for answers on how to get their world to stop moving.

Dizziness is Even Harder to Treat

Another challenge with dizziness patients is that medications don’t really do a good job of making the world stop moving. Many patients with chronic dizziness are placed on anti-depressants, anti-anxiety meds, and drugs for nausea. The problem with that is that the patient may not be as nauseated, but their brains are not responding to their environment appropriately.

Dizziness after spinning on a bat is easy to explain, but what if the world is spinning when you're standing still?

Dizziness after spinning on a bat is easy to explain, but what if the world is spinning when you’re standing still?

 Dizziness can also be treated by positional maneuvers like the Epley maneuver and head shaking exercises like gaze stability. Both are extremely effective when they are used appropriately, but can be useless if it’s performed on the wrong patient with the wrong diagnosis.

That’s why it’s so important to know what’s really going on with a patient. Many clinics will take any person with dizziness and just do some of these maneuvers even though the maneuvers may not be appropriate for the patient’s specific condition. In order to help a patient recover, we have to examine them closely to make sure that we have the right information to begin care.

Case Study: 

Recently we had a patient come in with dizziness and had been seeing an ENT for treatment. She was having problems feeling off balance for a while and it was made with head turning sometimes. She wasn’t experiencing a spinning type sensation, but just a sense of feeling out of sorts.

The doctor diagnosed her with benign paroxysmal positional vertigo or BPPV. It’s arguably the most common form of vertigo and is usually easily treated with a positional maneuver called the Epley maneuver. The doctor performed Epley and gave her some alternative maneuvers that she could do at home whenever she felt dizzy.

The problem was that the maneuver wasn’t changing anything. She tried doing the maneuvers for several weeks with no change. When she followed up with the doctor, the doctor told her there wasn’t anything else he could do and that some cases don’t respond.

Fortunately the patient found her way to our office through a referral from one of our patients who got really great results with balance problems

BPPV usually causes a spinning sensation that is really short lived. In many cases, doctors can diagnose BPPV with a test called the Dix-Halpike maneuver. You can look at this test below. If you have BPPV your eyes will start moving making a fast oscillating movement called nystagmus.

It’s this nystagmus when the inner ear moves the eyes that creates a feeling of spinning.

When this patient came in, we did a thorough history and found out that her “vertigo” didn’t have any spinning at all. She just felt disoriented and off balance. We performed the Dix-Halpike test and she had her eyes stayed solid.

So now we knew that she probably didn’t have BPPV, and that’s why the Epley maneuver didn’t work that well for her. It was time to figure out what other anatomy might be causing her problem.

We did a test called the smooth pursuit neck torsion test. It’s a test developed from patients who had dizziness after whiplash. It’s an indicator that the neck might be causing the eyes to move abnormally. You can see that test here below. In patients with neck problems, the eyes will start jumping instead of staying smooth.

Now that we knew the neck could be a problem, we started addressing the neck using the NUCCA procedure for structural correction.

Within 2 visits, the patient’s dizziness was about 80% gone. We have more work to do to help the neck heal, but with some time I think this patient will get back to normal.

Find the Cause, Deliver the Solution

So this isn’t an indictment on another professional. Lots of ENTs keep their focus on infections of the ear, nose, and throat. An ENT with a neurology background would probably have found the same thing and recommended physical therapy or chiropractic care.

The lesson here is that dizziness is complicated, and one treatment won’t solve all forms of dizziness. For any condition, we have to spend time with our patient, listen to their history, examine them thoroughly, and we can find a game plan to help them get back to normal.

Talk to Dr. Chung