Vertigo, Balance and Chiropractic

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org

Chiropractic and Vertigo

	The Barany Society Position on ‘Cervical Dizziness’ J Vestibular Research 2022 (Nov 15): 1–13 116 ~ FULL TEXT In summary, there are several confounds that make research into cervical dizziness challenging. Given the current data, we cannot at present, recommend any specific diagnostic criteria for cervical dizziness, nor can we presently recommend any specific therapy. We hope that investigators with a research interest in cervical dizziness can decrease the uncertainty over this putative clinical entity, by designing rigorous clinical trials via multi-centre, randomised, blinded, controlled studies.
	Cervicogenic Dizziness in an 11-Year-Old Girl: A Case Report Adolesc Health Med Ther 2021 (Nov 26); 12: 111–116 ~ FULL TEXT Cervicogenic dizziness (CGD) is a syndrome of neck pain accompanied by a false sensation of unsteadiness and dizziness due to neck pathology. An 11-year-old girl presented with neck pain and dizziness for four months. According to the patient's statement, her complaints were likely related to the prolonged smartphone use for texting. Sagittal radiograph showed cervical kyphosis, anterior wedging of several vertebrae, and mild anterolisthesis of C2 on C3 and C3 on C4. These findings might be present in as physiological variants in children. However, continuous static stress in the minor variants could aggravate biomechanical problems, such as cervicogenic dizziness. After ruling out other neurological or vestibular problems, a multicomponent approach consisted of thermal ultrasound therapy, cervical manipulation, and intermittent motorized cervicothoracic traction to release cervical complaints. Three months later, the patient reported a resolution of neck pain and dizziness. At 12-month follow-up, all radiographic metrics showed improvement, including restoration of cervical alignment and lordotic curvature. The immature growing cervical spine has unique anatomic, physiologic and biomechanical features. A static neck flexion can lead to typical injury patterns seen in this age group. This article aims to raise awareness of the potential harms of excessive smartphone use by children.
	Chiropractic Treatment of Older Adults with Neck Pain with or without Headache or Dizziness: Analysis of 288 Australian Chiropractors' Self-reported Views Chiropractic & Manual Therapies 2019 (Dec 18); 27: 65 ~ FULL TEXT This is the first known study to investigate chiropractic care of older adults living with neck pain. The findings suggest that chiropractors use well-established manual and physical therapy techniques to manage neck pain in older adults. The favourable outcomes reported by participants highlight a potential role for using non-pharmacological multimodal therapeutic approaches for the management of neck pain in older adults. The findings also indicate that this target group of patients may frequently integrate chiropractic care with other health services in order to manage their neck pain. Understanding the patient’s motivation for using multiple services may shed light on the health care needs of this population. Further research should also explore how chiropractic treatment of neck pain in older adults impacts patient experience, and other patient-reported outcomes. Given the high prevalence of neck pain in older people, the evidence for the effectiveness of manual and physical treatments for neck pain, the reported demand for chiropractic care in this population, the barriers to pain relief, and concerns among older adults regarding polypharmacy, further studies are needed to provide a more solid evidence-base upon which clinical guidelines for chiropractic management and/or co-management of this condition can be developed. Until then, we recommend that the current clinical guidelines be followed.
	Cervicogenic Dizziness Oxford Medical Case Reports 2019 (Dec 9); 2019 (11): 476–478 ~ FULL TEXT Results from clinical studies [3–6] do show promise for the use of manual approaches in the treatment of Cervicogenic dizziness (CGD). The underlying mechanism for the efficacy of manual therapy includes stimulation of cervical proprioceptors and normalization of the afferent input. [14] It must be emphasized that manual therapies should be applied with great caution in patients with CGD. Ruling out neurovascular aetiologies is of utmost importance before starting the manual therapy to prevent any untoward events in CGD.
	Vestibular Dysfunction in Acute Traumatic Brain Injury J Neurol 2019 (Oct); 266 (10): 2430–2433 ~ FULL TEXT Central and peripheral vestibular dysfunction — often in combination — is common in acute TBI. Prospective studies are required to assess whether acute intervention improves patient outcomes.
	Approach to Cervicogenic Dizziness: A Comprehensive Review of its Aetiopathology and Management Eur Arch Otorhinolaryngol. 2018 (Oct); 275 (10): 2421–2433 ~ FULL TEXT In this narrative review, the various conditions causing cervicogenic dizziness have been discussed systematically, incorporating and segregating the existing literature as per the different categories. The classification of cervicogenic dizziness described is simple yet practical. The algorithm provided here for evaluating the suspected cases of cervicogenic dizziness seems appropriate and sensible. Nevertheless, since the algorithm is based on the extrapolation of facts from the literature, it needs further validation by clinical studies. Moreover, in some patients, dizziness could be due to a combination of cervicogenic cause and vestibular or neural deficits, the scenario which has been not addressed in the given algorithm.
	Chiropractic Treatment Including Instrument-assisted Manipulation for Non-specific Dizziness and Neck Pain in Community-dwelling Older People: A Feasibility Randomised Sham-controlled Trial Chiropractic & Manual Therapies 2018 (May 10); 26: 14 Recruitment of participants in this setting was difficult and expensive. However, a larger trial may be feasible at a specialised dizziness clinic within a rehabilitation setting. Compliance was acceptable and the outcome measures used were well accepted and responsive.
	The Effectiveness of Manual Therapy in Treating Cervicogenic Dizziness: A Systematic Review J Phys Ther Sci 2018 (Jan); 30 (1): 96-102 The role of manual therapy in managing cervicogenic dizziness remains unclear. The study identified moderate evidence favouring the use of manual therapy to manage cervicogenic dizziness. The review also showed a potential for manual therapy to improve the intensity, frequency and dizziness handicap inventory (DHI) of cervicogenic dizziness. However, further high quality trials are recommended to provide more conclusive evidence in this regard. Additionally, there is a need for further investigations comparing manual therapy treatments to other conservative interventions in this regard. Also, it is recommended to study the effect of manual therapy in a multimodal intervention plans. That will provide a more conclusive evidence of the rule of manual therapy in the treatment of cervicogenic dizziness.
	The Role of Chiropractic Care in the Treatment of Dizziness or Balance Disorders: Analysis of National Health Interview Survey Data J Evid Based Complementary Altern Med. 2016 (Apr); 21 (2): 138–142 The odds ratio for perceiving being helped by a chiropractor was 4.36 (95% CI, 1.17-16.31) for respondents aged 65 years or older; 9.5 (95% CI, 7.92-11.40) for respondents reporting head or neck trauma; and 13.78 (95% CI, 5.59-33.99) for those reporting neurological or muscular conditions as the cause of their balance or dizziness.
	Is There a Role for Neck Manipulation in Elderly Falls Prevention? An Overview J Can Chiropr Assoc. 2015 (Mar); 59 (1): 53–63 ~ FULL TEXT We conclude that chiropractors may have a role in falls prevention strategies in the subpopulation of the elderly that suffer from mechanical neck pain or dysfunction and non-specific dizziness. However, this role remains to be rigorously studied and properly defined.
	Chiropractic Management of Benign Paroxysmal Positional Vertigo Using the Epley Maneuver: A Case Series J Manipulative Physiol Ther. 2013 (Feb); 36 (2): 119–126 ~ FULL TEXT The patients underwent one or more canalith repositioning procedures (Epley maneuver). Scores in each of the categories decreased from the initial to 6-day assessment and then again at the 30-day assessment. The effects of the treatment on the Short Form 12 scores showed changes between the initial assessment and 30 days posttreatment. The patients in this case series demonstrated reduction in symptoms with chiropractic management.
	Comparison of Outcomes in Neck Pain Patients With and Without Dizziness Undergoing Chiropractic Treatment: A Prospective Cohort Study With 6 month Follow-up Chiropractic & Manual Therapies 2013 (Jan 7); 21: 3 ~ FULL TEXT Neck pain patients with dizziness reported significantly higher pain and disability scores at baseline compared to patients without dizziness. A high proportion of patients in both groups reported clinically relevant improvement on the PGIC scale. At 6 months after start of chiropractic treatment there were no differences in any outcome measures between the two groups.
	Manual Therapy With and Without Vestibular Rehabilitation for Cervicogenic Dizziness: A Systematic Review Chiropractic & Manual Therapies 2011 (Sep 18); 19: 21 ~ FULL TEXT There is moderate evidence to support the use of manual therapy, in particular spinal mobilisation and manipulation, for cervicogenic dizziness. The evidence for combining manual therapy and vestibular rehabilitation in the management of cervicogenic dizziness is lacking. Further research to elucidate potential synergistic effects of manual therapy and vestibular rehabilitation is strongly recommended.
	Chiropractic Management of a 40-year-old Female Patient With Ménière Disease J Chiropractic Medicine 2010 (Mar); 9 (1): 22–27 ~ FULL TEXT Treatment included primarily high-velocity, low-amplitude spinal manipulation to the upper cervical and thoracic spine, along with soft-tissue trigger-point therapy, and stretching exercises. Within 2 weeks of treatment, the patient's tinnitus had resolved; and all other symptoms (including vertigo) were improved. The patient's headaches, neck pain, and vertigo were subsequently resolved within 3 months of treatment. The patient experienced only 2 minor episodes of self-resolving "light-headedness" over that time. After 2½ years of follow-up, any occasional episodes of mild aural fullness and/or light-headedness are either self-resolving or relieved with cervical spinal manipulation and soft-tissue treatment.
	Improvement in Ataxia, Dizziness, & Visual Disturbance, in a Child with Vertebral Subluxations Undergoing Chiropractic Care: A Case Study J. Pediatric, Maternal & Family Health 2010; 2: 89–94 The patient is an 11-year-old female who had a one month history of dizziness, fuzzy vision, and inability to stand or walk unassisted. MRI revealed an anatomical variant in which the patient’s cerebellar tonsils protruded 2mm into the foramen magnum, and there was compression of the pituitary gland by cerebral spinal fluid (CSF). The patient was no longer able to attend school, or perform normal daily activities of an eleven year-old. Physical exam findings indicated the presence of vertebral subluxation at the atlas and occiput. Specific manual and drop table assisted adjustments were performed, primarily in the upper cervical region, based on evidence of subluxation. The patient responded well to care with complete resolution of cerebellar symptoms.
	Observation of Curative Effect on Fixed-point Spin Reduction of Spinal Manipulation Therapy for Cervical Vertigo Zhongguo Gu Shang. 2010 (Feb); 23 (2): 99–101 Fixed-point spin reduction of spinal manipulation therapy for cervical vertigo can accurately correct single or multiple vertebral body displacement, restore normal spinal position, reduce the oppression and stimulus of the vertebral artery, release ischemia of vestibular labyrinth, and eliminate the symptoms of vertigo.
	Effects of Chiropractic Care on Dizziness, Neck Pain, and Balance: A Single-group, Preexperimental, Feasibility Study J Chiropractic Medicine 2009 (Dec); 8 (4): 156–164 ~ FULL TEXT This feasibility study was conducted to further the development of a line of investigation into the potential effects of spinal manipulation/manual therapy on cervicogenic dizziness, balance, and neck pain in adults.
	Chiropractic Care for Nonmusculoskeletal Conditions: A Systematic Review With Implications For Whole Systems Research J Altern Complement Med. 2007 (Jun); 13 (5): 491–512 ~ FULL TEXT (1) Adverse effects should be routinely reported. For the few studies that did report, adverse effects of spinal manipulation for all ages and conditions were rare, transient, and not severe. (2) Evidence from controlled studies and usual practice supports chiropractic care (the entire clinical encounter) as providing benefit to patients with asthma, cervicogenic vertigo, and infantile colic. Evidence was promising for potential benefit of manual procedures for children with otitis media and elderly patients with pneumonia.
	Manual Therapy Treatment of Cervicogenic Dizziness: A Systematic Review Manual Therapy 2005 (Feb); 10 (1): 4–13 Dizziness is a common and often disabling disorder. In some people the cause of their dizziness is pathology or dysfunction of upper cervical vertebral segments that can be treated with manual therapy. The aim of the present study was to systematically review the literature on the manual therapy treatment of patients with cervicogenic dizziness, by identifying and evaluating both randomized controlled trials (RCTs) and non-RCTs (controlled clinical trials and non-controlled studies).
	Vertigo, Tinnitus, and Hearing Loss in the Geriatric Patient J Manipulative Physiol Ther. 2000 (Jun); 23 (5): 352–362 ~ FULL TEXT The patient received upper cervical-specific chiropractic care. Paraspinal bilateral skin temperature differential analysis was used to determine when an upper cervical adjustment was to be administered. Radiographic analysis was used to determine the specific characteristics of the misalignment in the upper cervical spine. Through the course of care, the patient's symptoms were alleviated, structural and functional improvements were evident through radiographic examination, and audiologic function improved.
	Cervical Vertigo After Hair Shampoo Treatment at a Hairdressing Salon: A Case Report Spine 2000 (Mar 1); 25 (5): 632–634 The authors suggest that the hyperextended neck position during hair shampoo treatment in a beauty parlor may be a risk factor for back lifting or cerebellum vascular insufficiency. Public education should lead to avoidance of this position during hair shampoo treatment at hair dressing salons.
	A Combined Approach for the Treatment of Cervical Vertigo J Manipulative Physiol Ther. 2000 (Feb); 23 (2): 96–100 Chronic, nontraumatic, cervical and shoulder-girdle dysfunction was an important causal and perpetuating factor of cervical vertigo in the population studied, and a consistent improvement was observed with the use of a conservative treatment protocol involving multiple modalities for patients with cervical vertigo. Further controlled studies are needed to access its validity.
	Clinical Study on Manipulative Treatment of Derangement of the Atlantoaxial Joint J Tradit Chin Med 1999 (Dec); 19 (4): 273–278 The derangement of the atlantoaxial joint is one of main cervical sources of dizziness and headache, which were based on the observation on the anatomy of the upper cervical vertebrae, analysis of X-ray film of the atlantoaxial joint, and the manipulative treatment in 35 patients with cervical spondylosis. The clinical diagnosis of derangement consists of: dizziness, headache, prominence and tenderness on one side of the affected vertebra, deviation of the dens for 1 mm-4 mm on the open-mouth X-ray film, abnormal movement of the atlantoaxial joint on head-rotated open-mouth X-ray film. An accurate and delicate adjustment is the most effective treatment.
	Vertigo in Patients With Cervical Spine Dysfunction European Spine Journal 1998; 7 (1): 55–58 60% of the patients examined were assessed with upper cervical dysfunction, and 77.4% of them responded favorably to spinal manipulation.
	Therapy of Functional Disorders of the Craniovertebral Joints in Vestibular Diseases Laryngorhinootologie 1992 (May); 71 (5): 246–250 Cervicogenic vertigo is caused by functional disorders of the craniovertebral joints. The therapeutic effect of chiropractic treatment in 28 patients with vertigo and purely functional disorders of the upper cervical spine or with a combination of functional disorders of the upper cervical spine and the labyrinth was evaluated. In our opinion chiropractic treatment is mandatory for the therapy of patients with vestibular affections and functional disorders of the craniovertebral joints.

Chiropractic and Balance or Proprioception

	A Systematic Review of Chiropractic Care for Fall Prevention: Rationale, State of the Evidence, and Recommendations for Future Research BMC Musculoskelet Disord 2022 (Sep 5); 23 (1): 844 ~ FULL TEXT Falls in the older population represent a large and growing public health issue. Based first on principle, multimodal chiropractic care shows promise in contributing positively to fall prevention efforts. In addition, the chiropractic profession is well positioned for implementation on a wide scale, however, to date limited evidence is available. Through a well-coordinated set of observational, mechanistic and randomized-controlled studies, this evidence gap can be filled and the potential of multimodal chiropractic care can be evaluated. Future research on falls and mobility represents both an exciting area of contribution for the chiropractic profession and a critical topic for public health.
	Effectiveness of Chiropractic Care to Improve Sensorimotor Function Associated With Falls Risk in Older People: A Randomized Controlled Trial J Manipulative Physiol Ther. 2016 (May); (39) 4: 267–278 Over 12 weeks, the chiropractic group improved compared with the control group in choice stepping reaction time (119 milliseconds; 95% confidence interval [CI], 26-212 milliseconds; P = .01) and sound-induced flash illusion (13.5%; 95% CI, 2.9%-24.0%; P = .01). Ankle joint position sense improved across the 4- and 12-week assessments (0.20°; 95% CI, 0.01°-0.39°; P = .049). Improvements were also seen between weeks 4 and 12 in the SF-36 physical component of quality of life (2.4; 95% CI, 0.04-4.8; P = .04) compared with control.
	Joint Position Sense Error in People With Neck Pain: A Systematic Review Manual Therapy 2015 (Dec); 20 (6): 736–744 Several studies in recent decades have examined the relationship between proprioceptive deficits and neck pain. However, there is no uniform conclusion on the relationship between the two. Clinically, proprioception is evaluated using the Joint Position Sense Error (JPSE), which reflects a person's ability to accurately return his head to a predefined target after a cervical movement.
	The Role of Chiropractic Care in the Treatment of Dizziness or Balance Disorders: Analysis of National Health Interview Survey Data J Evid Based Complementary Altern Med. 2015 (Sep 11) The key findings in this study were that improvements were observed in the chiropractic group in joint position sense error, sound-induced flash illusion, and CSRT compared with the control group. Between-group differences were also observed in the physical component of health-related quality of life, with the chiropractic group improving compared with the control group between the 4- and 12-week assessments.
	Is There a Role for Neck Manipulation in Elderly Falls Prevention? An Overview J Can Chiropr Assoc. 2015 (Mar); 59 (1): 53–63 ~ FULL TEXT We conclude that chiropractors may have a role in falls prevention strategies in the subpopulation of the elderly that suffer from mechanical neck pain or dysfunction and non-specific dizziness. However, this role remains to be rigorously studied and properly defined.
	The Effects of Manual Therapy on Balance and Falls: A Systematic Review J Manipulative Physiol Ther. 2012 (Mar); 35 (3): 227–234 ~ FULL TEXT A limited amount of research has been published that supports a role for manual therapy in improving postural stability and balance. More well-designed controlled trials with sufficient participant numbers are required to draw meaningful clinical conclusions about the role that manual therapies may play in preventing falls or improving postural stability and balance.
	Geriatric Chiropractic Care as a Health Promotion and Disease Prevention Initiative: Focus on Fall Prevention Topics in Integrative Health Care 2010 (Dec 30); 1 (2) ~ FULL TEXT The chiropractic profession is well positioned to align itself with the principles of health promotion and disease prevention championed by the World Health Organization. As a means to explain how chiropractic practice models and the WHO position statements can converge, this article will use the example of fall prevention. This article will discuss the epidemiology, risk factors, patient assessment tools and preventive strategies of falls prevention for older patients.
	Chiropractic Care for Older Adults: Effects on Balance, Dizziness, and Chronic Pain J Manipulative Physiol Ther. 2009 (Jul); 32 (6): 431–437 ~ FULL TEXT Falls are an important public health concern, making major contributions to death, disability, and health care costs in older adults. [1] Because of the importance of fall prevention to the well-being of the aging population, as well the extremely high health care costs associated with falls, the evidence base on this topic is growing exponentially. At least 16 controlled studies have been done examining the contribution of various risk factors to falls. [2] Lower-extremity weakness, balance, and gait deficits are the top risk factors. [2] Interventions that target these have been shown to reduce risk of falls.
	Pilot Study of the Effect of a Limited and Extended Course of Chiropractic Care on Balance, Chronic Pain, and Dizziness in Older Adults J Manipulative Physiol Ther. 2009 (Jul); 32 (6): 438–447 ~ FULL TEXT Falls are one of the chief public health concerns for older adults, being the leading cause of nonfatal injury and comprising two thirds of all unintentional injury deaths in this population. [1] Direct medical costs of falls are estimated to be $6 to $8 billion per year. [2] Not only is the number of older adults increasing, but also the fall death rates have increased significantly from 1988 to 2000 for both men and women. [3]
	Feasibility Study of Short-term Effects of Chiropractic Manipulation on Older Adults With Impaired Balance J Chiropractic Medicine 2007 (Dec); 6 (4): 121–131 ~ FULL TEXT Falls are the leading cause of nonfatal injury in older adults and account for two thirds of all unintentional injury deaths in this population. [1] Direct medical costs of falls have been estimated at $6 billion to $8 billion per year. [2] Furthermore, fall death rates have increased significantly from 1988 to 2000 for both men and women. [3]
	Assessment of Balance and Risk for Falls in a Sample of Community-dwelling Adults Aged 65 and Older Chiropractic & Osteopathy 2006 (Jan 27); 14: 3 ~ FULL TEXT A total of 101 participants enrolled in the study. Advertising in the local senior newspaper was the most effective method of recruitment (46%). The majority of our participants were white (86%) females (67%). About one third (32%) of participants had a baseline BBS score below 46, the cut-off point for predicting risk of falling. A mean improvement in BBS scores of 1.7 points was observed on the second visit. For the subgroup with baseline scores below 46, the mean change was 4.5 points, but the group mean remained below 46 (42.5).
	Single-Leg Balance Dynamic Chiropractic (May 7, 2005) ~ FULL TEXT Even if your practice is not involved in any formal program to rehabilitate balance and proprioception, it is still worthwhile to inform your patients of the interaction between subluxation and balance. The following patient education article is designed to be useful regardless of whether or not you are deeply involved in rehabilitation. Please feel free to use it for bulletin-board display, front-desk handouts, lay lectures or tableside talks.
	Effects of Acupuncture, Cervical Manipulation and NSAID therapy on Dizziness and Impaired Head Repositioning of Suspected Cervical Origin: A Pilot Study Manual Therapy 2000 (Aug); 5 (3): 151–157 The effects of different forms of therapy-and none-on dizziness and neck pain were compared, using a 100 mm visual analogue scale (VAS). Active head relocation by subjects with dizziness was significantly less precise than in the control group. Manipulation was the only treatment to diminish the duration of dizziness/vertigo complaints during the past 7 days and increased the cervical range of motion. Both acupuncture and manipulation reduced dizziness/vertigo on the VAS scale and had positive effects on active head repositioning.
	Cervicocephalic Kinesthetic Sensibility, Active Range of Cervical Motion, and Oculomotor Function in Patients with Whiplash Injury Arch Phys Med Rehabil 1998 (Sep); 79 (9): 1089–1094 Active head repositioning was significantly less precise in the whiplash subjects than in the control group. Failures in oculomotor functions were observed in 62% of subjects. Significant correlations occurred between smooth pursuit tests and active cervical range of motion. The results suggest that restricted cervical movements and changes in the quality of proprioceptive information from the cervical spine region affect voluntary eye movements. A flexion/extension injury to the neck may result in dysfunction of the proprioceptive system. Oculomotor dysfunction after neck trauma might be related to cervical afferent input disturbances.
	The Effects of Spinal Manipulation on Cervical Kinesthesia in Patients With Chronic Neck Pain: A Pilot Study J Manipulative Physiol Ther 1997 (Feb); 20 (2): 80–85 Subjects receiving manipulation demonstrated a mean reduction in visual analogue scores of 44%, along with a 41% improvement in mean scores for the head repositioning skill. In comparison, a 9% mean reduction in visual analogue scores and a 12% improvement in head repositioning scores was observed for the stretching group. The difference in the outcomes of the head repositioning skill scores was significant (p < or = .05).
	Therapy of Functional Disorders of the Craniovertebral Joints in Vestibular Diseases Laryngorhinootologie 1992 (May); 71 (5): 246–250 In our opinion chiropractic treatment is mandatory for the therapy of patients with vestibular affections and functional disorders of the craniovertebral joints.
	Chiropractic Effects on Athletic Ability Chiropractic: The J Chiro Res and Clin Invest 1991; 6 (4): 84–87 In this study, chiropractic researchers gave chiropractic adjustments to an experimental group, while the control group was simply monitored. Reaction time was measured before the season began and at six weeks. In the control group, the improvement in reaction time at the six-week check-up was less than 1 percent. On the other hand, the experimental group's reaction time was 18 percent faster.

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