Balance issues still unresolved 3 years down the line

[alan31]

Hi all,

this is my first time on this forum, am looking for some advice if at all possible. A brief history: I started feeling unwell 3 years ago. By unwell, I mean a vague feeling of motion sickness, or mild nausea, not unlike car sickness. This is totally persistent, but varies in intensity - when its at its worst I really just need to lie down and cannot work, as I have difficulty focusing, cannot concentrate. 3 years ago I lived in Scotland, and had all the blood tests, GP checks, and various opinions. All test came back negative, and i was told it was probably a virus, to stay healthy, and it would burn itself out. Later, I realised that I had tinnitus, and full ears - the GPs ruled out ear issues, however, (based on my ability to snowboard) and I was left to get on with it. I should say that the only way I found relief was through excercise, or through a sauna (has been suggested this was my body and muscles warming up). I moved to Australia 2 years ago, and immediatley went to see a GP. CT scans (brain) and audiology testing were negative. ENT assessed me, had MRI and further audiology done - negative. He said my symptoms were consistent with central disorder. I have been seeing an OT who recognised tight SCM - she performed trigger point treatment with success - I feel much better for the day, but wake up the next day feeling sick again. Chiro xrays show mild pelvic tilt, mild scoliosis and severe sublaxation of c1 c2. His adjustments again make me feel better for a day or tw, but it does not last. I have a cross bite, had splint therapy done (6 months) with 0% improvment. I am now seeing a physio, who has been doing active release on my suboccipitals among others - same effect..feel better for a day or two. My SCMs are now improved, but my left scalene is hyper tight. Something I find when I am feeling really ill is that my back around my tailbone is very tight, and I even ripped a muscle on the left side at this area recently. I apologise for the length of this, but theres a lot of info. There seems to be some perpetuating factor here, which my health care providers cannot see.....can anyone help? I have been trying so hard with the various stretches etc which have been recommended, but nothing seems to work! Thanks in advance.

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[MrPhysio+]

Hello Alan,
It is possible that you have tight Cx muscles due to your body trying to resist the motion sickness feel. Have you tried the technique for reducing vertigo called the Epley manoevre?
This is designed to work on inner ear disturbance. You may have a mild case of this causing your postural muscle tightness. The technique is fairly simple and painless.
MrPhysio+

[alophysio]

Hi Alan31,

Excellent history. I totally understand your frustration.

About the inner ear, I am sure your visit to the ENT would have assessed that right? I personally don't think you have vertigo, esp if you have had tests and ENT assessment. They love that sort of stuff - i have a good friend who is an ENT so i hear about tinnitus and vertigo all the time - that is, i know they are familiar with the problems!

It sounds to me that you have a neck problem. This is evidenced by the fact that OT, chiro and physio both help for a short time.

What is missing though is WHY the neck is under pressure. Now it would seem that no-one has put their finger on it (so to speak!) because the pain keeps coming back. We call this "finding the driver" - that is, trying to work out what is causing the neck and muscles around it to be under so much pressure that you get the symptoms.

From my experience, if you had your neck tested and your therapists are confident that it is causing the SYMPTOMS and have been treating the neck, then the problem may be further away like in the ribs/thorax or lower.

You mention that you snowboard - that involves a lot of twisting and falling ( ) so it is certainly not outside the realms of possibility that it is a thoracic spine dysfunction.

You may find your therapists say "it is hard to get this neck to release" or something to that effect - that is very common when it comes to treating an area that is under pressure from somewhere else.

Have a play yourself or get a friend/partner/hired person to press on various tender spots on your ribs/chest/back - when they press on the right spot, your neck will free up a bit more and you may even feel better immediately. This is what i do with a client to show them how various parts of the body can give them the symptoms and then we have to work out a way to keep that area under control - that can be HARD! But it can also be easy and good fun

All the best - let us know how you get on

Cheers

[MrPhysio+]

Interesting comments that I feel require a reply. My suggestion re a mild case of vertigo is based upon the fact that three years of musculoskeletal therapy has failed to address your problem as well as your description of motion sickness etc. ENT exclusion of severe disease does not exclude what I am suggesting. I have been involved with tinnitus patients for many years and have written a patient study on the subject. I am also involved with musculoskeletal and sports treatments and treated head injured neurological patients for many years. Although I often speak with people and have friends in many professions I do not profess to have their qualifications or to give advice regarding their professions based upon occasional conversations.
There may well be other explanations for your symptoms, but in a search for relief it would be unwise to discard suggestions out of hand unless they are totally illogical.

[alophysio]

Hi MrPhysio+,

No offence intended about your comments, i think the structure of the sentences above in post probably put things wrong...

1. I am not dismissing vertigo or tinnitus, just saying that i know how much my ENT friend knows about those ailments and that i would have thought that ENTs would be looking at those diagnoses. I don't profess to be an ENT or have his knowledge because he is a friend.

2. I was acknowledging his (the OP's) frustration. The next sentence should have been a new para because it is a new topic. I will edit this to remove an ambiguity. I wasn't having a go at you, merely expressing my opinion which was different to yours. You believe it could be vertigo related neck muscle tightness. I believe it could be something else. No problems there - we both have not seen the patient and can only go on what has been said.

So again, i apologise if you felt i was somehow personally attacking you...it was not my intention.

@Alan31 - i forgot to ask - do you have tinnitus?

Thanks!

[MrPhysio+]

Thanks for the quick apology - accepted. Alan has stated that he had tinnitus : line 7 on his post.

[alophysio]

thanks -
about the question of the tinnitus...i saw the tinnitus remark but he then said GP ruled out ear issues - just confirming if he has neurological tinnitus or possibly referred pain into the ears...or did the GP mean that he didn't have tinnitus, etc etc...

..so i should ask the question better

@alan31 - do you have tinnitus confirmed as a diagnosis by your GP or even better your ENT? Or do you still have symptoms like tinnitus now?

Thanks!

[MrPhysio+]

Sorry to be pedantic, but if a patient states that they have tinnitus it means they have abnormal sounds that they hear. There is no test to refute that a patient is hearing any particular sound. It is possible to match a particular frequency to what a patient states they are hearing, but you cannot tell them they don't have tinnitus. Where the tinnitus is being generated is another matter entirely.
The symptoms, at least initially, match what I know to be similar to otolith caused irritation. Tinnitus tone and volume can be changed by pressure over the scalp, mastoid, external auditory meatus and jaw pressure / alignment including Cx musculature - but the previously mentioned structures do not permanently change tinnitus. Therefore treatment to the Cx may alter symptoms of tinnitus, motion sickness and nausea in the short term partially due to Cx baroreceptor changes as musculature temprarily relaxes. Balance is complex, as you know, with many inputs to the brain having to match or disparate input causes delayed neural processing, a lag, resulting in the nausea, motion sickness etc. Postural change then occurs in the postural muscles in an attempt to stabilise input to the brain by reducing stimulus that causes symptoms. A learned response then occurs along with increased muscle tone that creates increased activity and then muscle shortening from the increased tone. Just some more thoughts to add into the discussion mix before I get some sleep!

[alophysio]

Thanks MrPhysio+,

no need to apologise for being pedantic

I have no problem with what you have said...

...but i want to hear from the OP what the deal is with what he considers to be tinnitus.

Rather than put the idea in his head as to all the different things tinnitus can be, i would rather him tell me - which is why i asked - i wasn't clear on what was going on from his history. If he had been sitting in front of me, i would have cleared it up straight away (just like every one does when they want clarification during a S/E) but since he isn't, i thought i would ask now

Thanks for your thoughts

Cheers

[alan31]

Thankyou both so much for your swift replies. To clarify a couple of points: I have only experienced vertigo on a handfull of occasions, my symptoms being restricted to a car sickness like dizziness without actually experiencing the spinning thing. I usually get a brief, mild episode of vertigo when I lie back on a dentists/chiros bed, flat on my back; this goes after approx 10 secs. I also experienced this after swimming freestyle, after which I stopped swimming. It may be worth noting I took up swimming, which I did nearly every day, about 6 months before falling ill - is there potential for poor technique and lack of stretching to cause problems? Regarding the tinnitus, I have had a high pitched hissing noise in both ears for approx 2.5 years; this is accompanied by my ears being blocked, or full. On a few occasions, after neck adjustment which have left me feeling particuarly good, (this will sound weird) my left ear gets a kind of cool sensation through it for a day or so. Eustachian tube opening?I briefly mentioned in my last post how I was treated for TMJ due to a crossbite - the NMD who undertook the treatment performed kinesiology testing showed that my jaw was effecting my balance (I had much more strength biting a pencil than not biting a pencil).However, we did 6 months of treatment to the letter, and absolutely no change occured. Based on this, I would be pleased to rule out the problem coming from my jaw, except for the fact that I think my left disc is dislocated from the TMJ, as I can feel it. I know the can press against the middle ear and cause problems. I should say, however, I have absolutely no jaw pain or headaches. Regarding my posture, I have a anterior head carriage (doing chin tucks), sway back and a "duck bum". I was not aware my posture until about a year ago when I started to research this properly, so am unsure how long I have been this way. To be honest, I feel lost with all this.....I have been trying so hard with various stretching programmes, ice, pilates, buteyko technique, all the health care providors under the sun and more cash then I could ever afford, and.......very little progress. The only positive change I have experienced has been through the neck treatments. Thankyou again for your advice, it is hugely appreciated! I will now go and look up the Epley manoevre, and get my wife to check for trigger points!

Many thanks,

Alan

[MrPhysio+]

Thanks Alan,
The following may be of assistance. I can send you more info if you let me know your email address.
Title: Vertigo: Quick and Easy Treatment
"Vertigo: Quick and Easy Treatment"
ST. PAUL, Minn -- May 26, 2008 -- A new guideline developed by the American
Academy of Neurology (AAN) found that the best treatment for vertigo is the easiest
and quickest one. The guideline on benign paroxysmal positional vertigo (BPPV), an
inner ear disorder that is a common cause of dizziness, is published in the May 27
issue of [Neurology, the medical journal of the AAN.
BPPV is believed to be caused by loose calcium carbonate crystals that move in the
sensing tubes of the inner ear. The maneuvers move the calcium crystals out of the
sensing tube and into another inner chamber of the ear, from which they can be
absorbed.
In many cases BPPV can be treated with simple maneuvers, such as a series of head
and body movements performed by a doctor or therapist while the patient sits on a
bed or table. There are several maneuvers currently in use for vertigo. The guideline
found that canalith repositioning procedure, also called the Epley maneuver, is safe
and effective for people of all ages. The Semont maneuver may be an effective
treatment as well.
The guideline also evaluated whether restrictions on activity are needed after the
maneuvers are performed. "There is no clear evidence to support these restrictions,
which include sleeping upright and wearing a cervical collar," said Terry D. Fife, MD,
Associate Professor of Clinical Neurology Vertigo and Ataxia Clinic, University
Neurology Clinic, University of Arizona College of Medicine, Phoenix, Arizona, and
Director, Arizona Balance Center, Barrow Neurological Institute, also in Phoenix.
The guideline also reviewed whether patients can perform the maneuvers safely and
effectively at home. "Having patients treat themselves using home exercises seems to
pose little risk, but there is not sufficient evidence that this is as effective as
maneuvers done by a doctor or therapist," said guideline author Dr. Fife.
"The good news is that this type of vertigo is easily treated," said Dr. Fife. "Instead of
telling patients to 'wait it out' or having them take drugs, we can perform a safe and
quick treatment that is immediate and effective."
SOURCE: American Academy of Neurology

[Dr Damien]

At Mr Physio

Acknowledging your expertise on the above subject, I said the following with total respect of your opinion. The Epley's maneovre is not likely to work here, these symptoms do not suggest a BPPV. I agree that the problem may be central, however I also acknowlege the fact that neck treatments are giving some form of relief. The word BPPV, "benign" which is the keyword indicates that the dizziness is never constant, it lasts for a few seconds or slightly more...more constant dizziness opens up a new field to explore with regards a possible diagnosis

What seems to tally in this situation is the evidence of a c1-c2 subluxation... the tightness of the neck muscles, the relief after specific neck treatment that lasts for a day or two..for a dizzy patient who experiences symptoms constantly, this is significant...

BPPV we all know is easy to diagnose, you only confirm suspicions with audiological tests... all these tests have come back negative from two different countries, the gentleman has not reported dizziness from head movements...

Maybe his problem is not from the ear afterall...I agree that having some fullness in the ears makes the history quite confusing,

the gentleman can try the epleys maneovre but we cannot ignore the subluxation of the upper cervical spine vertebrae, if this is the root of all the problem attempting the Epleys maneovre can worsen the situation...

cheers

[MrPhysio+]

Thanks for your comments Dr Damien, but I tend to disagree. Just out of curiosity, are you a chiropractor or osteopath? Alan has stated that he discontinued swimming because it aggravated his symptoms eg head turning with breathing. Re subluxation of C1-2 : I have not seen the scans but tend to avoid giving such diagnoses much creedance, just my personal experience. I am not going to enter a debate about the veracity of 'subluxation' diagnosis as that debate rages elsewhere. Alan has clearly stated his subjective symptoms and I have made comment. The Epley treatment if carried out correctly will not cause Cx problems. It is true that if a patient has vertigo then the patient will feel some vertigo and possibly nausea whilst having the Epley treatment. The irritation is very short lived and tends to confirm the diagnosis and reason for doing the treatment. Alan should not be scared of the treatment because of your comments. In fact, as you say, he can try the treatment. Hopefully other people commenting on this case will read what Alan has actually said regarding his symptoms, the advice he has been given and what he has found helps him, even if only temporarily. I can tell that Alan is very frustrated, as he should be and all of us commenting should be sensitive to his request for help without creating confusion.

[Dr Damien]

To Mr Physio and Alan31

I missed Alan31's entry yesterday. Lying back on a table and getting dizzy lasting 10 seconds does indicate a possible positional effect (Hallpike dix maneovere type assesment). Mrphysio may be right that this could be a case of BPPV then...you have also said that your dizziness is not constant which is also possible an indicator for a BPPV

Dear Alan31 have you ever been assessed for BPPV then?

To Mr Physio, I am a physiotherapist...not an osteopath/chiro, my comments are not intended to scare anybody. We have to be careful what advice we give to people we are not seeing, so i take into consideration every symptom that is said, i consider every possible contraindication and make the client aware. It is called educating a patient, that is what this forum is for. It is not for proving that anybody is knowledgeable. whether or not this problem is a BPPV, the client has reported some radiological evidence of a subluxed C1-C2, who are we to discredit what we are not seeing?

I believe you have quite good reason to reason as you do, and if i had read Alan31's last comment I may have agreed with you quickly. Rather than advice an Epley's maneovere , I would advise to be assessed for BPPV first, because this is jumping the gun...remmeber that these maneovers are pasted over the internet and cn be easily carried out, but when somebody has reported they have been told that C1-c2 is subluxed...then the safest advice I would give is to go back to a trained professional with these knew thoughts because, with an epleys maneovre...your are going to extend your neck, you are going to rotate it...often enough you may have to repeat this two or three times to see an effect...

The aftercare after Epley's maneover is the most crucial part of the treatment not the treatment itself...Mr Physio may be right in the sense that neck adgustments might temporarily move loose crystals, but since a BPPV diagnosis has not been confirmed the after care of that is lacking causing a comeback of the symptoms...

To Alan31, again i ask, has anyone assessed you for a BPPV?
To Mr Physio, thank you for the lateral thinking...like i said, my words should not scare anyone, if my Alam31 tried the Epley's maneovre and suddenly started getting lower limb weakness how would you feel about that? or numbness in his arms...shouldnt he be seeing someone physically before trying something that may well have a contrainindication or caution attached to it...

Im just saying educating about safety first....

[alan31]

Hi all, and thanks for your opinions. Regarding BPPV, I am unsure if I have been assessed for this...I have been to so many doctors, and I can think of a number of occasions where I was put on a bed and had my head turned in certain ways, to test whether I got dizzy. However, I cannot remember the specifics, so...while it seems I have, I cannot say 100%. I think it would be wise to get my chiro or physio to test this to confirm. In saying this, I have also been to an ENT, and had audiology testing - would this not rule out BPPV? Perhaps I am looking at this wrongly, but the mild vertigo occurs less than 0.1% of the time, and is hardly a problem. What is a massive problem to me is the remaining 99.9% of the time feeling car sick and foggy brained. Could the crystals causing BBPV also be causing this? I appreciate there is only so much you can tell me through my descriptions. When speaking about not ruling anything out, I guess it is possible that both my ears and my neck are contributing? (touch wood). What would you folks do in my position? I live in Townsville, and, being a smallish and isolated town, I have limited access to specialist health care providers. If there was a balance disorder specialist who springs to mind as being my saviour, who works out of Melbourne, Sydney or anywhere else in Oz, I would consider visiting him. Thankyou all for taking an interest in my troubles, it is really appreciated.

[alophysio]

hi Alan31,

Given all the above, and having seen and successfully treated people like yourself, i still reckon the neck is more consistent with your condition than an ear problem. And because the effects [of treatment to the neck] are short-lived, i think that something else is causing the pressure on the neck - possibly the thorax. That is my honest opinion but it is only that - my opinion without having examined you . If i am wrong, that's cool...so long as no harm comes to you

There are people who specialise in balance issues. I am here in Sydney and i think there are a small handful of physios that ENTs refer to.

My ENT friend is here in Sydney and i know that he loves this stuff...i know that he could confirm if it is from the balance apparatus etc. I will ask him if there is an ENT in Townsville etc that he trusts. He is pretty connected.

By all means, MrPhysio+ and DrDamien all make good points. In the end, you will find out what is working and what isn't.

So again, find someone who is happy to to find the real cause of your problems and give you longer lasting relief and control of your neck and whatever is driving the neck problem (IMHO) Cheers!

[physiobob]

There's a pretty simple test anyone (even a family member) can do for BPPV. Any comments on the results of the approach outlined below. We should first look to confirm (not necessarily 100% of course) or otherwise.

Benign Paroxysmal Positional Vertigo (BPPV)?

How is BPPV diagnosed?
The most important means for diagnosing this condition is the physical examination and history of the patient. A patient with dizziness or vertigo without hearing problems suggests the diagnosis of BPPV. A normal ear exam, audiogram, and neurological exam are expected. A simple positional test, performed in the doctor's office, is usually all that is needed to confirm the diagnosis of BPPV.

One such test is the Dix-Hallpike test. First, the patient is positioned on the examining table, seated upright. Then the examiner brings the patient's head down over the edge of the table and turns the head to one side. If the patient has BPPV, the examiner will witness a characteristic movement of the eyes, call nystagmus, that begins after a few seconds. If the nystagmus is seen and the patient becomes dizzy, then the ear which is pointing toward the floor is the one with the loose otoconia. If no nystagmus is seen the examiner will repeat the test, this time turning the head to the opposite side, thus testing the other ear.

This nystagmus and perception of vertigo will slow down and cease after 15 to 20 seconds. If the head is not moved, no further symptoms will occur. When the patient sits back up, the dizziness will recur, but for a shorter period of time. Lying down on the opposite side will not cause the vertigo. Occasionally, in order to confirm the extent of the inner ear dysfunction, an electronystagmogram (ENG) will be ordered.

Here's some more info on a non-drug, non-surgical treatment approach for BPPV

The Epley or Semont Maneuver

Researchers have found that a simple and well-tolerated physical therapy technique performed in the office can relieve the vertigo in a high percentage of patients. The Otolith Repositioning Procedure of Semont and Epley has become well accepted and is based on using gravity to move the crystals away from the nerve endings into an area of the inner ear that won’t cause any problems. Sometimes, a vibrator is placed on the mastoid to "liberate" the particles and improve the procedure's success.

Here's a youtube link:

Watch the video animation and notice that as the patient is moved into the various positions of the maneuver, the posterior semicircular canal is rotated in such a way as to deposit the displaced otoconia back into the vestibule where they can do no further harm.

There's also a self help treatment for this here:

Some authors comment that approximately 75% of patients are cured with one maneuver. This percentage increases with repeated treatments. Following the maneuver, patients must not lie flat for 48 hours, meaning they should sleep in a recliner or propped up on pillows. Also, after 48 hours, patients should not lay down on the affected ear for at least one week following the treatment. Even tying shoes or bending over should be avoided during this week. These instructions help prevent the crystals from falling back into the balance chamber.

[MrPhysio+]

Thanks PhysioBob, the information provides a clear view of how to test one possibility which may explain Alan's symptoms. Alan, the mild symptoms you have can indicate a mild case of BPPV ie not causing the room to spin. ENT testing has not found anything sufficient to be of concern, but this does not mean that something of a low level to cause symptoms has been ruled out. There are many tests for many things however as good as tests can be they do not always pick up abnormalities. ENT specialists are generally not concerned with symptoms that are of a low grade and unlikely to cause serious problems even though the patient can be seriously disaffected by the problem. The usual response from a specialist is that no life threatening or progressively damging disease is present so the patient should be happy to live with the symptoms. Most patients are unhappy with this view and persevere in looking for relief.
Without changing my mind on the Epley suggestion, it should also be stated that low grade sinus or nasal congestion can cause car sickness and foggy head due to eustachian tubes not equalising pressure at the back of the ear drum. Such problems and BPPV can be missed by ENT exams and scans. You may have a mild case of allergy - if so have you tried non sedating anti histamines, sinus wash out or steam inhalations? Before taking antihistamines you should check with your Doctor or Pharmacist especially if you have not taken them before.
To answer some questions - Yes your symptoms can be caused by BPPV. I do not think you need a balance disorder Specialist at this stage. If you have a Physiotherapist in Townsville familiar with the Epley treatment see them. Ask the Australian Physiotherapy Association Queensland Branch who in Townsville could help you. If you cannot find someone that has done the procedure I can provide someone of your choice with information, but they could just as easily look it up. Yes it is possible that the neck and inner ear are acting together, as explained in my previous posts. The symptoms you have can cause secondary effects.
My comments to Dr Damien about the C1-2 subluxation were made because Chiropractors use this terminology. Were you neck X-Rays done by and reported to a Chiropractor?
I can guide you through the other suggestions (steam inhallation, sinus washout )if you wish, just let me know.

[alophysio]

hi

Thanks Physiobob and MrPhysio+ for the info.

In defence of my ENT friend (who is not Alan's specialist) he is concerned about the mild symptoms as well as the surgical ones...but i acknowledge that MrPhysio+ said that he was speaking in general

Still reckon it is your neck

Cheers!

[alan31]

Thanks again for your replies. I have looked through my records, and have noted that a GP conducted the Hall Pike Maneuver, and that it was negative. My OT also said she tested me for vertigo through head movements, also negative. Would this rule out BPPV, or do you think I should still have the Epley test, to be sure? I have also noted that the ENT report stated that the ENG report "reported as consistent with a central disorder and not of a peripheral or ear disorder". Can I ask what an ENG report is? I will go to the pharmacy to try the antihistemines next.

Thanks again, cant tell you how grateful I am.

Alan

[MrPhysio+]

Hello Alan,

Thanks for the further information. Try this link to help explain the various testing eg ENG : VESTIBULAR TESTING

It has been my belief that the Epley treatment (not a test) may help you. Your symptoms are mild on the scale of things regarding BPPV therefore may not be picked up by testing looking at the eye movement. Try the Epley treatment, at least it rules out one other thing. The antihistamines or other sinus type treatments may clear the foggy head.

Overall stress and constant symptoms will increase the neck tension, as I explained initially. Keep us informed of your progress.