Chiropractic for the treatment of vestibular disorders (2023)

Many people may think that a chiropractor will automatically "break the neck" of every patient they see, including patients suffering from motion sickness. Spinal manipulation, whether performed by a chiropractor, physician, osteopath, or physical therapist, may or may not be an appropriate intervention for a patient. There are particular cases where spinal manipulation should be avoided and these “absolute contraindications” and “red flag symptoms” are well known.¹. Chiropractors, like other healthcare professionals, are trained to select the most appropriate treatment for a patient and may use alternative types of manual therapy when spinal manipulation is not indicated. Chiropractors treating vestibular patients will determine treatment based on the individual diagnosis.

"I'm dizzy and you want to break my neck?"

Safe, effective, and appropriate treatment can only be determined following a detailed history and examination. Patients with dizziness or other symptoms suggestive of a vestibular disorder should await a detailed diagnosis before recommending any treatment program, regardless of which healthcare professional they consult. It is especially important for vestibular patients to choose chiropractors and health care professionals who have received specialized training in vestibular disorders.

There is growing public interest in learning more about how chiropractors help people with vestibular disorders. This is due in part to reports in the media.²describing the successful treatment of "high profile" figures including Sidney Crosby and CNN anchor Colleen McEdwards by Florida chiropractor Dr. Ted Carrick, who is one of approximately 600 chiropractors worldwide who are sometimes referred to as "certified chiropractors." Neurologists” or “Neurological Chiropractors”, titles that can sometimes be confusing for those working outside the profession.

Training

Chiropractic shares commonalities with other health professions such as occupational therapy, osteopathy and physical therapy. All four professions contain special interest groups with a focus on neurology. Those working within these groups are sometimes referred to as "neurological chiropractors" or "neurological physical therapists" and should not be confused with physicians who specialize in neurology (i.e., neurologists). In most cases, physicians in these special interest groups have obtained postgraduate qualifications in fields related to neurology or neurological rehabilitation, and sometimes specifically vestibular rehabilitation.

Chiropractors with a special interest in neurology and neurological rehabilitation have the opportunity to pursue additional graduate studies from approved programs that may specifically include vestibular rehabilitation. For example, candidates who demonstrate competency on written and practical exams may receive Certification from the American Board of Chiropractic Neurology (ACNB).³. ACNB is fully accredited by the National Commission of Certifying Agencies (NCCA)⁴, an organization created in 1987 to “help ensure the health, well-being and safety of the public by accrediting certification programs and/or organizations that assess professional competence”. The NCCA uses a rigorous peer review process to establish accreditation standards for a wide range of professions and occupations, including dentistry, nursing, occupational therapy and pharmacy. Finally, chiropractors also share the same opportunity as their colleagues in medicine, occupational therapy, osteopathy and physical therapy to take specific "independent courses" in vestibular rehabilitation. The excellent program “Vestibular Rehabilitation – A Course by Skills”⁵Led by Emory University School of Medicine and led by Dr. Susan Herdman, Dr. Neil Shepard, Dr. Richard Clendaniel and Dr. vestibular patients. (Note: In the US, this course is limited to physical therapists.)

Diagnosis and treatment

The diagnosis and treatment of vestibulopathies are complex. Patients often describe feelings of dizziness, however it is important to note that dizziness is a general term often used to describe symptoms of dizziness, feeling off-balance, geocentric vertigo (when the world seems to revolve around the patient). ) or egocentric vertigo (when the patient feels that he is spinning and the world is still), or a combination of the above. Therefore, it behooves the physician to spend time with each patient, listen and take a careful history, and follow up with a detailed and proper examination.

Chiropractors with postgraduate certification in vestibular rehabilitation are well positioned to help patients who present with dizziness or other symptoms suggestive of a vestibular disorder.

It is important to note that a critical distinction is made between dizziness caused by "peripheral" and "central" disorders.⁶. Peripheral vestibular disorders (such as benign paroxysmal positional vertigo or cervicogenic dizziness) can usually be treated "in the office" and often respond well to specific manual therapies such as "Channel Repositioning Treatment" or cervical spine manual therapy.⁷respectively. Central vestibular disorders (such as vestibular migraine, persistent postural perceptual dizziness formerly known as chronic subjective dizziness, traumatic brain injury or stroke) often require co-management with other healthcare professionals (such as a physician or psychologist) or, in some cases, very urgent forward.

How do “neurological chiropractors” certified in vestibular rehabilitation help patients with vestibular disorders? It is beyond the scope or intent of this article to detail all possible diagnostic tests and treatment programs that may be appropriate to help a patient with a vestibular disorder. Instead, let's look at three brief case examples to give you an idea of ​​what a patient can expect when seeing a physician with a similar background. Remember that every case is different and successful treatment is always "patient centered" and tailored to the person. In other words, no two treatment programs are alike because no two cases are exactly alike.

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Case 1

June, a 64-year-old pensioner, arrived at the clinic after 4 days of struggling with vertigo and dizziness. He explained that she had woken up a few days earlier and, as she turned over to her left side in bed, suddenly felt a violent "falling" sensation, as if "the whole room was spinning" for a minute or so. June said it had happened a few times since then, though not as badly, and she felt "a little wobbly and dizzy". June was usually fine and rarely got sick, although she did tell us that she was in bed with a cold for a few days before that happened.

When June came to her initial appointment, most of the scan was completely normal (as is often the case). June's history was compatible with the diagnosis of Benign Paroxysmal Positional Vertigo (BPPV) and this was confirmed with special tests.⁸. We also noticed some stiffness in June's neck, which was probably not surprising given her age and the fact that she was trying to keep her neck stiff for fear that the vertigo would come back. The good news is that this problem usually responds well to a treatment known as a "canal repositioning treatment" (also known as an "Epley maneuver").⁸. With June's consent, we continued the treatment and a friend took her home. We gave June advice on sleeping position and she returned to the clinic 2 days later "feeling 100%". We repeated the special tests, which came back normal, so June was discharged home with a recommendation to return if the symptoms returned.

Case 2

Mary, a 46-year-old pharmacy assistant, presented to the clinic with a 5-month history of dizziness and feeling "dizzy". She reported that her symptoms were worse when she was tired and when she walked or shook her head rapidly. He also felt worse using the computer and this, along with the "busy" visual background of the pharmacy, made his work increasingly difficult. Mary said that she felt her symptoms start a few weeks after feeling dizzy in bed one night. She had seen her doctor at the time, who diagnosed her with an ear infection. Mary admitted that although the vertigo completely subsided within about a day, she found the experience extremely frightening and was worried it might happen again. She had seen her doctor several times over the last few months, who had arranged for an MRI scan (which was normal) and prescribed antidepressants. Mary said the antidepressants helped at first, but she stopped taking them after a few months because she felt her sleep was getting worse.

When Mary attended her initial consultation, much of her examination was completely normal. However, we noticed that he was breathing a little fast and shallow most of the time and that his neck was quite stiff. special tests⁹Observing the relationship between her neck, her eyes, and her sense of balance suggested that at least some of her problems were related to tight muscles and joints in her upper neck.

We explained to Mary that her symptoms were more like persistent postural perception dizziness (formerly known as chronic subjective dizziness) and cervicogenic dizziness. We agreed to a treatment program that included home exercise (including vestibular rehabilitation therapy^10,11, controlled breathing exercises and relaxation techniques) and office consultations (including gentle manual therapy to reduce neck stiffness and monitor your exercises at home). We were careful to ensure that Mary's treatment was safe and that she was comfortable with all procedures used. Mary attended the clinic for nine weeks and reported a gradual reduction in all of her symptoms until she was symptom-free at discharge.

Case 3

Susan, a 34-year-old housewife, presented to the clinic with a two-year history of intermittent vertigo. She described the vertigo attacks, which lasted from a few seconds to a few hours, as severe and it often felt like her head was "spinning inside". Susan said that she often felt nauseous and sometimes vomited when the vertigo was particularly severe. She said that it was rare for more than two weeks to go without an attack of vertigo and that she had noticed that she was more likely to have an attack if she was tired or stressed. Susan admitted that she often "had a bit of a stiff neck" and that she was a "headache" person. Susan had a younger sister who apparently suffered from migraines. Susan's family doctor ordered an MRI when her symptoms started, which was normal.

As with Mary, Susan's examination was normal. We noticed a moderate amount of stiffness affecting many of the muscles and joints in her neck, including some "trigger points" (areas of localized muscle tightness). He also had a little trouble with some balance tests. Susan's history of headaches, her family history of migraines, the "self-centered" nature of her vertigo, and a relatively normal scan raised the possibility of an underlying "central" cause. However, as Susan's previous MRI was normal, it was unlikely that there was a "structural" problem in her brain causing her vertigo.

We explained to Susan that her case seemed compatible with the diagnosis of vestibular migraine. While the precise mechanism underlying vestibular migraine is not yet fully established, research suggests that it may be a "central" disorder caused by abnormal function of some parts of the brain.^12,13,14. This is consistent with our current understanding of migraine, which is now also considered a brain disorder.

We explained to Susan that, based on our experience with similar cases, a blended care approach would likely be successful. For this reason, we recommend a treatment program that includes home exercise (including vestibular rehabilitation therapy and relaxation techniques), dietary guidance for migraine, and office consultations (including gentle manual therapy).¹⁵to reduce neck stiffness and monitor your workouts at home). As with all patients, great care was taken to ensure the safety of Susan's treatment and to ensure that she was comfortable with all procedures used.

In addition to the above, we also offer Susan an innovative treatment known as “QEEG Guided Neurofeedback”. QEEG-guided neurofeedback can be considered a specific "brain training" and has been shown to be effective in reducing headache frequency in patients with recurrent migraine.^sixteenand in the clinic we have also found it useful in the treatment of patients with vestibular migraine. Susan attended the clinic for 16 weeks and reported a gradual reduction in all of her symptoms until, on discharge, she happily reported almost complete resolution of her symptoms.

While it is not important that you know everything about vestibular disorders, it is very important that the healthcare professional you are seeing does! It would be wise to find out the experience and level of training of any healthcare professional you are considering by asking them directly. That way, you can be sure you're in good hands.

Disclaimer: Many of the treatment examples described in this article can also be performed by a specially trained physiotherapist or occupational therapist. It is critical that vestibular patients verify the qualifications and experience of chiropractors or other medical professionals in evaluating and treating patients with inner ear disorders before agreeing to a treatment plan. We recommend coordinating all medical care with your primary care physician.

About the author

The Doctor. Daniel Lane is a Registered Chiropractor practicing in Perth, Western Australia. He is certified by the American Chiropractic Neurology Board (ACNB) and completed certification in vestibular rehabilitation with Dr. Susan Herdman and colleagues. In addition to seeing patients in private practice, Dr. Lane also works as a Permanent Fellow in Neuroscience and Neurodevelopment at the School of Occupational Therapy and Social Work based at Curtin University, Perth, Western Australia.