This case series presents the clinical assessment and diagnosis of two patients with persistent vertigo from two separate etiologies who remained refractory to typical interventions; and discusses the outcomes of individualized, targeted, multisystem management provided by a chiropractor.
Vertigo is defined as the sensation of self-motion when no self-motion is occurring or the sensation of distorted self-motion during otherwise normal movement.1 Vertigo may have a number of etiologies which include vascular, neoplastic, infectious, toxic or physiologic.1
In this case series, two patients suffered from physiologic forms of vertigo. The diagnoses included persistent postural perceptual dizziness (PPPD) and Mal de Debarquement syndrome (MdDS). Both were diagnosed by neurootology specialists and remained refractory to standard interventions.
Background
One male, age 54, diagnosed with PPPD, and one female, age 55, diagnosed with MdDS, were referred from other health care providers for assessment and management of their persistent vertigo. Previous interventions included medications (betahistine, escitalopram, fluoxetine), cognitive behavioural therapy, upper cervical spinal manipulation, exercise therapy, mindfulness meditation, and vestibular rehabilitation.
Case #1
A 54-year-old man employed at a telecommunications company presented with persistent vertigo of two years duration. He was seen by neurootology and subsequently diagnosed with PPPD. His PPPD was thought to have been caused by a viral infection which led to acute vestibular neuritis. At the time of presentation, his previous treatment included: betahistine, escitalopram, cognitive behavioural therapy and vestibular rehabiliation.
His symptom burden at initial assessment included: vertigo, anxiety, visual motion sensitivity, depression, nausea, and poor short term memory. He completed the Dizziness Handicap Inventory and Visual Vertigo Analog Scale and scored 68/100 and 60/90, respectively.
Physical examination was completed and revealed a pleasantly interactive man, with good attention and focus. Pulse 88, right-sided BP 130/83, left-sided BP 135/84. Oxygen saturation 99%. Gait was grossly normal. Upper and lower extremity light and sharp touch, as well as, joint position sense was normal. Pathological reflexes were absent. Reflexes were 2+ bilaterally at all levels. No evidence of pyramidal paresis, atrophy, flaccidity, spasticity or motor spontaneity noted.
Infrared oculography revealed low-frequency left beat nystagmus in all seated head positions (i.e.: head right, left, up, down, tilt) with visual supression. Bedside assessment of smooth pursuits revealed saccadic intrusions downward and leftward. Optokinetic gain was reduced leftward. Choice reaction time was normal. Antisaccade error rate was 30%. Convergence was insufficent at 17 cm. Cervical spine joint position error was signficant in all directions.
Balance assessement was performed using posturography and showed severely reduced balance in mCTSIB and cervical challenge testing for his age and gender. Other physical examination procedures including cranial nerve assessment, muscle tone, tandem stance, tandem gait, dual task gait, and cervical orthopedic testing were unremarkable.
Case #2
A 55-year-old female office administrator presented with persistent vertigo of six months duration. She was seen by neurootology and diagnosed with MdDS. Her presentation was classic of MdDS, as her symptoms began following a 10-day cruise in the Carribean. Upon returning to dry land, her vertigo began and would only remit while travelling in a car.
At the time of presentation previous treatment included: betahistine, fluoxetine, psychotherapy and approximately 10 Epley maneuvers performed bilaterally.
Her symptom burden on initial assessment included vertigo, anxiety, irritability, poor short-term memory, visual motion sensitivity, and brain fog. She completed the Dizziness Handicap Inventory and Visual Vertigo Analog Scale and scored 38/100 and 50/90, respectively.
Physical examination was completed and revealed a pleasantly interactive woman with good attention. Pulse 66, oxygen saturation 98%. Gait was grossly normal. Upper and lower extremity light and sharp touch, as well as joint position sense, were normal. Pathological reflexes were absent. Reflexes were 2+ bilaterally at all levels. No evidence of pyramidal paresis, atrophy, flaccidity, spasticity or motor spontaneity noted.
Infrared oculography revealed low-frequency right beat nystagmus in right and left tilt, head extension, and post vertical and horizontal headshake testing with visual suppression. Bedside assessment of smooth pursuits revealed saccadic intrusions downward, up left and down right. Optokinetic gain was reduced rightward. Ocular alignment, convergence, accomodation, cover/uncover, peripheral vision and cardinal gaze were all normal.
Balance assessement was performed using posturography and showed severely reduced balance in mCTSIB and cervical challenge testing for her age and gender. Other physical examination procedures including cranial nerve assessment, muscle tone, tandem stance, tandem gait, dual task gait, and cervical orthopedic testing were unremarkable.
Multisystem Management Approach
Both patients received targeted treatment that matched their clinical dysfunction. Broadly, these strategies were gaze stabilization exercises, ocular movements (smooth pursuits, saccades, OKN, vergence), spinal manupulation, motor coordination interventions, somatic sensorimotor complex movements, and isometric contractions.
Each patient performed targeted exercises tailored to their dysfunction. Case #1 performed right horizontal canal VOR x1 and VOR x2 exercises. VOR x1 involves the patient maintaining gaze on a stationary target while simultaneously rotating the head in the associated canal plane, which in this case was the right horizontal canal. VOR x2 is similar; however, in this exercise the target is not stationary. It will move equal and opposite in direction to the head turn (e.g., head rotates right while target moves left).
Case #1 also performed right upper and lower extremity sensorimotor complex movements, eye-head pursuits horizontally, and leftward optokinetic stimuli in the horizontal and torsional planes.
Case #2 performed on-axis rightward rotations while simultaneously being exposed to rightward optokinetic stimuli. She also performed left horizontal canal VOR x2 exercises, vergence pursuits in right gaze, and saccadic eye movements corresponding to the left semicircular canal planes. The saccadic eye movements were performed while wearing a weighted vest with the goal of increasing somatic-proprioceptive input.
Both patients were instructed to perform these exercises for 15 minutes two days per day for 21 days. At seven days, both patients returned for follow-up appointments to assure they were performing the exercises appropriately at home.
Outcomes
Both patients demonstrated complete symptom resolution at three-week follow-up. Both scored 0/100 on DHI and 0/90 on VVAS. Interestingly, all complaints that were non-vertiginous in nature were also eliminated in both patients. Follow-up infrared oculography was performed and nystagmus was absent in both cases.
This short case series demonstrates subjective and objective improvements in two patients with persistent vertigo of dissimilar etiology following a multisystem, individualized and targeted rehabilitation program.
Reference
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