In the past month, we’ve talked quite a bit about vertigo, how vestibular therapy can help with vertigo, migraines, or dizziness, and also about how chiropractic care can help with recovery in such vertigo cases. Today, we’ll go through a real life case study of the ups & downs that can happen with someone suffering from vertigo as it often is not a straightforward journey!
Vertigo in a 53-year-old Female
Mrs G, a 53-year-old female came in October 2021 complaining of dizziness the past week without any reason (insidious onset). Dix-Hallpike test was POSITIVE on the left side (read more about some clinical tests to diagnose vertigo here!) but there did not seem to be any other aggravating factors. Ruling out any head injuries, blood pressure issues, and also the fact that she had been complaining of a very stiff neck in the past week, we proceeded with chiropractic treatment.
Initial Treatment
Treatment administered focused on vertigo treatment positions through the Epley’s manoeuvre and also on soft tissue release for the muscles around the neck. Once the neck stiffness was relieved, chiropractic adjustments were given to the neck and midback to relieve joint stiffness as well. After 2 sessions of similar treatment, she was feeling better and the dizziness had reduced to about 50%. However, she still mentioned that there were moments where her nausea increased during exercise and that she was having difficulty falling asleep.
Considering that Epley’s manoeuvre is extremely effective in the case of a true BPPV (success rates range from 72%-92% after the initial application of Epley’s manoeuvre within the first 1 week), it would seem that Mrs G’s case of vertigo had other underlying factors.
Her third session was with our physiotherapist who taught her eye movement exercises to help with eye-gaze stability (this is often implicated in causes where movements like exercise or even being in a moving car can cause nausea) and also taught her desensitisation positions like the Brandt-Daroff exercises to be done daily. Subsequently, her dizziness gradually resolved and she was sent off as a happy patient!
Remission and Relapse
However… Vertigo can often be a tricky thing. A medical database on vertigo states that one-third of patients have a remission at 3 weeks, and majority remit at 6 months. There also tends to be an increase in the incidence happening in females, and over 3 years there is a 50% chance of it recurring!
This was the case with Mrs G. Nearly 6 months later, she came in again reporting that the dizziness had come back. However, the examination this time showed some different results: A NEGATIVE Dix-Hallpike test, dizziness unable to be reproduced, and the main sensation being tightness over her neck and upper back which overall did not feel like her previous vertigo episode in 2021. Her main complaint was dizziness at the end of the day when she laid down in bed, without any other activities triggering her dizziness.
Second Round of Treatment
Initially suspected to be a somatosensory referral from cervical and thoracic stiffness, physiotherapy & chiropractic treatment was administered but after 6 sessions of rehabilitative exercise focused on the neck & midback, and vertigo desensitisation movements, there did NOT seem to be a remarkable improvement in her dizziness whenever she started to lie down in bed and get up.
One session was also spent monitoring her blood pressure during transitional movements, lying down, and getting up without any remarkable changes which ruled out any postural hypotension-related vertigo. Due to the lack of progress, we referred her to an ENT to check if there was any other underlying condition going on.
ENT Referral Returns
A check with the ENT showed that they suspected Mrs G was suffering from vestibular migraines. Unlike traditional migraines, the dizziness may NOT be accompanied by headaches but may still trigger vertigo symptoms in people who have had a previous history of migraines (which Mrs G did)! Interestingly enough, the treatment was a mild-dosage antidepressant for a month, after which the dizziness reduced and Mrs G was referred back by the ENT for further physiotherapy.
After another session of physiotherapy where we administered some joint mobilisation around the neck to relieve stiffness, and recapped some exercises that should be done at home, Mrs G went off on a holiday and reported that she was already feeling much better without need for further sessions!
Conclusion
This case study just goes to show that treatment of vestibular issues usually isn’t such a straightforward process, and that there may oftentimes be other factors that come into play. Physiological factors that we cannot control include gender, age, and genetic predisposition. External factors can be related to weakness or stiffness around the neck region affecting nerves and causing vertigo, or even the lack of eye-gaze control that can contribute to symptoms.
For the patient’s best interest, a thorough check always needs to be done and a willingness to be humble enough to refer out to a specialist once things don’t seem to be progressing. After all, a healthy quality of life is what we all aim for for all our patients – not personal accolades. Working together can only bring the best out of each case.