Persistent Postural Perceptual Dizziness and cervical spine instability
Ross Hauser, MD
If you have been diagnosed with Persistent Postural Perceptual Dizziness, it may have been explained to you by your doctors that this is a mystery ailment with an unknown cause. Nonetheless, you have episodes of dizziness, but the room does not spin. You have a problem where you feel like you are swaying like being on a boat, but to other people around you, you are not swaying at all.
As you are reading this article, you may be looking for answers because you are not getting any and your problem continues.
- A battery of tests and a process of elimination to discover a cause of Persistent Postural Perceptual Dizziness.
- Is it all in your head? Hypersensitivity to pain and non-central sensitization cases of persistent postural-perceptual dizziness (PPPD).
- Treatment of Persistent postural-perceptual dizziness.
- Treatments of Persistent postural-perceptual dizziness that may have been suggested to you but may not have helped.
- Selective serotonin reuptake inhibitors (SSRIs) and Serotonin and norepinephrine reuptake inhibitors (SNRIs) for Persistent Postural Perceptual Dizziness.
- A focus on vestibular rehabilitation exercises, for the neck, and shoulders for Persistent Postural Perceptual Dizziness.
- Once these causes were eliminated, something else needed to be found that is causing Persistent Postural Perceptual Dizziness.
- I still don’t understand my Persistent Postural Perceptual Dizziness diagnosis.
- The Sensory Organization Test.
- One in five of these people had a neck problem. Understanding the Persistent Postural Perceptual Dizziness diagnosis in the patient with cervical spine instability.
- The neck, the vagus nerve, and Persistent Postural Perceptual Dizziness.
- Arterial and venous obstruction of fluid into and out of the brain.
- Vagus nerve problems or problems of vagal tone.
- The Vagus Nerve, Persistent Postural Perceptual Dizziness, and the other conditions you may suffer from.
- Persistent Postural Perceptual Dizziness and vestibular rehabilitation therapy.
- The connection between cervical neck instability and neurologic and vascular type disorders.
- Is an answer to Persistent Postural Perceptual Dizziness to be found in damaged and weak cervical spine ligaments?
A battery of tests and a process of elimination to discover a cause of Persistent Postural Perceptual Dizziness
In November 2021 a paper was published in the Journal of Neurology (1) looking for a neurological understanding of persistent postural-perceptual dizziness (PPPD) and its main characteristics of “chronic subjective dizziness, visual vertigo, and related diseases. . . ” Among eighty patients diagnosed with PPPD, the doctors looked for “conditions of hypertension, diabetes, smoking, and drinking. . .” Then blood work was done looking at “total cholesterol, triglyceride, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, fibrinogen, vitamin B12, folic acid, total cholesterol, triglyceride, and folate level.”
The test subjects were examined by carotid artery CT angiography and cranial MRI, and the imaging findings of carotid atherosclerosis (CAS), white matter hyperintensities (predictors of increased risk of stroke, dementia, and death), and lacunar infarction (small vessel atherosclerosis and lipohyalinosis (vessel wall thickening) related to hypertension or embolic occlusion) were recorded.
Is it all in your head? Hypersensitivity to pain and non-central sensitization cases of persistent postural-perceptual dizziness (PPPD)
A March 2022 paper in the journal BioPsychoSocial Medicine (9) compared the clinical features of central sensitization (an over or hypersensitivity to pain caused by neurologic issues) and non-central sensitization cases of persistent postural-perceptual dizziness (PPPD) who visited a psychosomatic medicine department at the researcher’s hospital. Dizziness symptoms were stronger in the central sensitization group than in the non-central sensitization group. The central sensitization group also had a higher distribution of smokers and greater anxiety and depressive symptoms.” The researchers suggested that their results revealed the effect of central sensitization as a factor that exacerbated the dizziness symptoms of persistent postural-perceptual dizziness.
For more on complex regional pain syndrome (CRPS)
Treatment of Persistent postural-perceptual dizziness
This article focuses on the treatment of cervical spine instability as a means to restore normal blood flow in and out of the brain and to alleviate problems of pinched cranial nerves. This will be explained below. Typically the treatment of cervical spine instability is not thought of as the forefront of treatment for PPPD. As mentioned in the research above a neck problem was identified in one of five patients. This indicates that treatment of cervical spine instability would not be effective for many people with PPPD. But the treatment of cervical spine instability could be effective for many others.
Treatments of Persistent postural-perceptual dizziness that may have been suggested to you but may not have helped
That you are reading this article is an indication that you are looking for other treatments for your problems of dizziness. Your doctors may have recommended to you various therapies. An underlying theme in treating Persistent Postural Perceptual Dizziness is that many treatments and remedies may be needed.
Selective serotonin reuptake inhibitors (SSRIs) and Serotonin and norepinephrine reuptake inhibitors (SNRIs) for Persistent Postural Perceptual Dizziness
In the publication StatPearls (10) at the National Library of Medicine, the guidelines for the treatment of Persistent Postural-Perceptual Dizziness is that there is not a single treatment method for it. The authors write: “It is essential to understand that dizziness may arise from central, peripheral as well as vascular conditions. For symptomatic relief of dizziness and feelings of unsteadiness, it has been shown that Selective serotonin reuptake inhibitors (SSRIs) and Serotonin and norepinephrine reuptake inhibitors (SNRIs) can help. Vestibular balance rehabilitation therapy can help manage motion stimuli by training and integrating the movement of eyes, head, and body movements.”
Selective serotonin reuptake inhibitors (SSRIs) and Serotonin and norepinephrine reuptake inhibitors (SNRIs) are anti-depressant medications. They come with side-effect warnings.
In 2002, doctors at the Department of Psychiatry, Hospital of the University of Pennsylvania investigated the effectiveness and tolerability of selective serotonin reuptake inhibitors (SSRIs) for the treatment of patients with dizziness and major or minor psychiatric symptoms, with or without neurotologic illnesses They reported their findings in the journal Archives of Otolaryngology-Head & Neck Surgery (11)
To investigate the efficacy and tolerability of selective serotonin reuptake inhibitors (SSRIs) for the treatment of patients with dizziness and major or minor psychiatric symptoms, with or without neurotologic illnesses. Sixty patients were treated with an SSRI for at least 20 weeks during the 30-month period. The patient’s ages ranged from 13 years old to 80 years old. They suffered from:
- Psychogenic dizziness (dizziness attributed to anxiety, depression, somatization disorder (for example dizziness caused by anxiety).
- Dizziness and hearing disorders are caused by a neurotologic condition. (Balance problems and hearing disorders caused by Meniere’s disease, Migraine, Vestibular neuronitis, and Benign positional vertigo, among others.)
- Idiopathic dizziness. (Unknown origin).
Results: Thirty-eight (63%) of 60 patients and 32 (84%) of 38 patients who completed treatment improved substantially. The response rates did not differ between patients with major psychiatric disorders and those with lesser psychiatric symptoms. Patients whose only diagnosis was a psychiatric disorder and those with coexisting peripheral vestibular conditions or migraine headaches fared better than patients with central nervous system deficits (headaches, loss of sensation, cognitive disorders). Before being treated with an SSRI, two-thirds of the study patients took meclizine hydrochloride and/or benzodiazepines (anti-histamines), with minimal benefit.
In 2021, researchers continued to build on these findings. Writing in the Journal of Neurology (12) researchers assessed the predictors of response to selective serotonin reuptake inhibitors (SSRIs) for 12 weeks in patients with persistent postural-perceptual dizziness (PPPD). Short-term treatment responses were studied in 197 outpatients (127 (64.5%) women, average age of about 52 years old) diagnosed with PPPD.
Results: “The overall response rate to pharmacotherapy was 65.0% (128/197). Being female and having greater disease severity at the baseline (higher CGI-S score – degree of assessed mental illness in the patient) were associated with a better response to the pharmacotherapy. Subgroup analyses by sex identified younger age and lower anxiety as the indicators for better outcomes in men, and the absence of comorbidities in women. During the initial assessment, the severity of PPPD was associated with depressive symptoms and subjective functional handicap due to dizziness. The response to pharmacotherapy is favorable in PPPD.”
A focus on vestibular rehabilitation exercises, the neck, and shoulders for Persistent Postural Perceptual Dizziness
Vestibular rehabilitation exercises are a broad description of trying to address the many problems of dizziness. For the people for whom it worked, some report the long process of retraining their brains to accept the “right” messages from the legs, eyes, and ears as to where this person was in relation to the ground where they stood. Some people found that if they do a lot of walking, this retrains the brain to understand and accept the right “balancing” messages. Still for others, exercising the neck and shoulder areas may offer some benefit as it may reduce spasms and tightness and possibly reduce compression on nerves, or as we will see veins and arteries.
Vestibular rehabilitation exercises are part of the treatment program for many forms of dizziness, as stated above. A December 2020 study in the journal Brain Behavior (4) suggests that “Therapeutic principles comprise cognitive-behavioral therapy, vestibular rehabilitation exercises, and serotonergic medication (serotonin reuptake inhibitors (SSRIs) antidepressant.) Follow-up observations after multimodal interdisciplinary therapy reveal an improvement in symptoms in most patients with chronic dizziness.”
A 2018 study in the journal Practical Neurology (5) suggested that “Once recognized, PPPD can be managed with effective communication and tailored treatment strategies, including specialized physical therapy (vestibular rehabilitation), serotonergic (antidepressants) medications, and cognitive-behavioral therapy.”
Once these causes were eliminated, something else needed to be found that is causing Persistent Postural Perceptual Dizziness
Here is a research study (2) from a team of Brazilian specialists that tries to outline what Persistent Postural Perceptual Dizziness is. This paper was published in 2015 soon after the 2014 formalization of the term “Persistent Postural Perceptual Dizziness” as a diagnostic classification. Here is what these researchers shared with their fellow doctors.
“with no clinical explanation for its persistence”
“Persistent postural-perceptual dizziness is the dizziness that lasts for over three months with no clinical explanation for its persistence. The patient’s motor response pattern (the simplest explanation is your ability to perform more than one motor skill at a time, for instance, walking and talking at the same time), presents changes and most patients manifest significant anxiety.”
This same study however does list a series of symptoms and conditions associated with Persistent Postural Perceptual Dizziness. First, let’s look at the people who were in this study:
- 81 patients, average age: 50
- There were almost six times as many females.
- The main reasons for these people’s dizziness were:
- visual stimuli or the movement of people or objects in the field of vision (74%),
- The people’s own body movements, such as turning their head quickly (52%),
- and sleep deprivation (38%).
The most prevalent comorbidities (other conditions these people suffered from) were:
- Hypercholesterolemia or high cholesterol (31%),
- Migraine headaches (26%), (Please see my article Vestibular migraine and spontaneous vertigo – Migraine Associated Vertigo).
- Carbohydrate metabolism disorders (22%) – these are problems related to diabetic ketoacidosis a diabetes complication of overproduction of blood acids, hyperosmolar coma – a diabetes complication of severe hyperglycemia, and hypoglycemia. All of these problems impair and suppress the central nervous system, sometimes dangerously, sometimes as a life-threatening situation.
- And cervical syndrome (21%). One in five of these people had a neck problem.
You may have had your doctor explain Persistent Postural Perceptual Dizziness as a possible diagnosis because you have a history of concussion or whiplash or previous or simultaneous diagnoses of Benign paroxysmal positional vertigo, vestibular neuritis (an inflammation of the vestibular nerve, a nerve in the ear that provides information to your brain to help keep you balanced,) Meniere’s disease, Dysautonomia (problems or disease of the autonomic nervous system) or Mal de debarquement syndrome which can cause that swaying feeling.
Even though you were told that you have Persistent Postural Perceptual Dizziness, and you may have some of the diagnoses and conditions mentioned above at the same time, you may still not have understood exactly what Persistent Postural Perceptual Dizziness (PPPD) is or what it describes and how it is different than these other problems you are facing. PPPD remains a mystery to you. In patients we see with a diagnosis of PPPD, some do not understand what this diagnosis is although they know they have it. These people and possibly yourself included, are not alone in having this problem not explained well.
I still don’t understand my Persistent Postural Perceptual Dizziness diagnosis
In a January 2021 study in the Journal of Vestibular Research: Equilibrium & Orientation (3) other doctors expressed concern that patients may not understand what their diagnosis of Persistent Postural Perceptual Dizziness means and in fact may understand it to mean something completely different than what was explained to them. This is what the researchers of this paper noted:
- Persistent Postural Perceptual Dizziness (PPPD) is a recently defined functional syndrome. (Formalized as a diagnosis in 2014). The researchers noted that this diagnostic term could create confusion or concern and possibly have negative patient effects. In interviewing patients with the PPPD diagnosis these doctors found:
Theme 1: Reassurance
- Some patients found reassurance and validation that they finally had a diagnosis or a “label” to describe this condition.
Theme 2: Fear of diagnosis
- Some patients were fearful of the diagnosis. That their situation, as bad as it may be currently, was actually worse. They felt better than they had a diagnosis but they felt scared that this diagnosis would lead to more serious health consequences and a lengthening of their medical journey.
Theme 3: Some patients had difficulty understanding terminology.
- Some of the patients did not understand the words of this diagnosis: Participants rarely understood “persistent”, “perceptual”, and “postural”. They did not tend to use the term “PPPD” with others or themselves. Some interpreted “persistent” as meaning “poor prognosis.”
Theme 4: How do I make sense of this diagnosis?
- The researchers noted a lack of psychological attribution. What does this mean? Since participants normalized the experience of distress, (tried to put it into terms that they could understand and manage) but did not view this as part of their PPPD diagnosis. (In other words, these people are coping and see a PPPD diagnosis as “just one more diagnosis for the pile.”)
Do you see yourself in any of the themes? A good guess is that many of you reading this article you probably see all these themes in yourself. You may have been glad you had a diagnostic label but then you were concerned that this would be just another diagnostic label among many that you have been given, some of which you may not even understand. In some cases, some people think that even their doctors do not understand what Persistent postural-perceptual dizziness is.
The Sensory Organization Test
In simplest terms, the Sensory Organization Test or Posturography is a test to help determine what causes you to sway. It tests a standing patient’s ability to maintain balance as proprioceptive (being able to walk without looking at your feet or touch your nose without looking at it) and visual sensory information is altered. The test may also be able to help determine the impact of visual perception, vestibular (inner ear disturbance), and proprioceptive systems to balance.
What are we seeing in this image? The ligaments of the upper cervical spine hold the cervical vertebrae and the skull in their correct alignment with each other.
In this article, we will discuss neck problems in people who suffer from dizziness. These neck problems include the upper cervical spine and craniocervical instability. This instability comes from damaged and weak cervical spine ligaments. In this illustration, we see C0-C2 ligament attachments. This includes the alar ligament, Co-C1 capsular ligament, C1-C2 capsular ligament, accessory atlantoaxial ligament, and the transverse ligament.
One in five of these people had a neck problem. Understanding the Persistent Postural Perceptual Dizziness diagnosis in the patient with cervical spine instability.
As we see, Persistent Postural Perceptual Dizziness (PPPD) can be “triggered” by many things and has symptoms and conditions related to a disrupted diabetes metabolism. If you are reading this article we will be focusing on the problem that one in five people in the above study had, cervical syndrome. They had neck pain and they suffer from conditions and symptoms consistent with craniocervical instability, upper cervical spine instability, cervical spine instability, or problems related to neck pain.
Problems related to neck pain may be an oversimplification and not truly reflective of the condition of the person who suffers from Persistent postural-perceptual dizziness. It is however a starting point for some people, a point of origin to help discover the causes and possible solutions to the challenges they face.
Concussion and whiplash
Some people who suffer from Persistent Postural Perceptual Dizziness have their origin of symptoms in a whiplash or concussion event. When they contact us they describe their challenges as ones that they have been dealing with for years. They tell us their stories and these stories have a common thread through them of conditions and symptoms of cervical spine instability. Their stories go something like this:
Over the last few years, I have been treated for post-concussion syndrome and PPPD. I have been dealing mainly with problems of occipital headaches, digestive disorders, a sensation of pressure in my head, or intracranial pressure. I have learned to live with these conditions although I wish they would go away. I have symptoms every day. I have no real treatment plan other than daily dealing with these symptoms daily.
In the people we see with similar medical histories, maybe like yourself, Persistent Postural Perceptual Dizziness is one of many conditions that they suffer from. In people with post-concussion syndrome, symptoms can be long-term, mysterious, and unexplained and their post-concussion syndrome has now turned into a persistent post-concussion syndrome. Please see our article: When persistent post-concussion syndrome turns into a neurologic mystery. It describes patients’ medical journeys and the challenges they face and how restoring cervical spine stability may help them.
Upper cervical instability and vestibular disorders
We will often be contacted by people who have a primary diagnosis of vestibular disorders of which Persistent Postural Perceptual Dizziness is considered one. Under the umbrella term vestibular disorders, the person’s Persistent Postural Perceptual Dizziness will be explained as a problem of the inner ear. These problems can also be interpreted as problems of:
- Cervical Vertigo and Cervicogenic Dizziness, Benign Paroxysmal Positional Vertigo, vertigo, and dizziness associated with neck movement.
Focus on the inner ear
- Vestibular migraine and spontaneous vertigo. In our article Migraine Associated Vertigo -Vestibular migraine and spontaneous vertigo we cite research that suggests that Vestibular migraine patients are abnormally sensitive to roll tilt (a misalignment of the eyes disrupting the sense of gravity and space), which co-modulates semicircular canal and otolith organ activity (this is an ability to sense gravity and sense motion), but not to motions that activate the canals or otolith organs in isolation (where fluid in the ears stabilizers balance), implying sensitization of canal-otolith integration. (Something is off but it is not a Meniere’s Disease type problem.)
For more on the problems of the inner ear and balance please see my article: When cervical spine instability causes ear pain, ear fullness, sound sensitivity, and hearing problems.
Again, what these people have in common is an existing diagnosis that they have some type of cervical spine instability. Further, their problem of Persistent Postural Perceptual Dizziness started shortly after vestibular migraine, acute vertigo, balance issues, dizziness, or vision motion disruption.
The neck, the vagus nerve, and Persistent Postural Perceptual Dizziness
Our treatments as mentioned, focus on cervical spine instability. We believe our treatments can help many people not only with PPPD but with the symptoms and conditions that accompany PPPD, symptoms, and conditions we see in cervical spine instability patients.
An August 2020 study in the Reviews in the Neurosciences (6) made these suggestions for the treatment of PPPD. There is a lot being said in this short paragraph. I will expand and explain the concepts. Here is what the researchers noted:
- Structural changes have been identified in the brains of PPPD patients, particularly in visual, vestibular, and limbic (behavioral and emotional responses) areas. These include a decrease in the volume and gyration of gray matter, a decrease in the blood flow to the cortex region, and alterations in the structural and functional connectivity, particularly in the visual-vestibular networks.
Let’s stop here for some explanation and visual aid to understanding.
What are we seeing in this image? Arterial and venous obstruction of fluid into and out of the brain
I like to explain to patients this vital component of their brain health, the ability to flush out waste fluids from the brain and replace these fluids with fresh fluid, as the analogy of a Brain Toilet Obstruction. The feedback from our patients made it clear this analogy seemed to resonate with them as the best way to understand the fluid in and fluid out of “brain draining.”
In the above study that we are exploring, a concern of “a decrease in the volume and gyration of gray matter, a decrease in the blood flow to the cortex region.”
In this split image, the image to the left shows a stable neck with a normal cervical spine curvature. Everything is in the cervical spine in its proper place. Cerebrospinal fluid drains and refills within the brain.
In the image to the right, we see cervical spine instability. The displacement of the C1 is exerting pressure on the arteries and veins leading into and out of the brain. The Cerebrospinal fluid is now backing up into the brain. In this situation, frontal lobe damage can occur.
The brain needs to drain out or flush out toxins and refill itself with fresh fluids. In the image to the right, it is pointed out that obstruction of the veins and arteries will cause a “clogged toilet.” What happens when the toilet clogs?
- The arteries that bring fresh oxygen, nutrients, and clean fluids to the brain will be impeded.
- The veins that help flush out toxic buildup will clog.
This may explain: “a decrease in the volume and gyration of gray matter, a decrease in the blood flow to the cortex region.”
What are we seeing in this next image?
A cause of the problems of intracranial pressure and impeded blood flow into the brain may be found in the relationship of the internal carotid artery to the upper cervical vertebrae. The internal carotid artery sits just in front of the transverse process of the atlas (C1) and the axis (C2) The blood flow of the internal carotid artery to the upper cervical vertebrae can be constricted or blocked by atlantoaxial (upper) cervical instability.
Vagus nerve problems or problems of vagal tone
Returning to the study published in the Reviews in the Neurosciences, the researchers concluded: “Selective serotonin uptake inhibitors and serotonin-norepinephrine reuptake inhibitors are the mainstay drugs for the management of PPPD patients. However, a significant proportion of PPPD patients do not show improvement in response to standard drug therapy. The employment of alternative and complementary treatment strategies, including vestibular rehabilitation therapy (neck and shoulder therapy), cognitive behavioral therapy, and non-invasive vagal nerve stimulation, is effective in the management of PPPD patients.
What are we seeing in this image?
If you look at the illustration below you will see where the Vagus nerve is closely related to the C1 – C2 – C3 vertebrae. While doctors usually discuss the vagus nerve in the singular sense, there are two vagus nerves, one on each side of the neck and in combination, they are referred to as the vagal nerves. This means that the degenerative damage in your neck can significantly impact the function of one or both vagus nerves. The one on the left side of your body and the one on the right side of your body.
The Vagus Nerve, Persistent Postural Perceptual Dizziness, and the other conditions you may suffer from.
When we started our work with patients with mystery ailments, conditions, and symptoms of cervical spine instability, we started focusing on the dysfunction of the Vagus Nerve as a primary factor and explanation for these problems. Medical research had long made a connection between “vagal tone” or vagus nerve function and neurologic and vascular type disorders.
Let’s look at an October 2018 study in the Journal of Neurology. (7) The title of this research is “Non-invasive vagus nerve stimulation significantly improves the quality of life in patients with persistent postural-perceptual dizziness.” It comes from the Department of Neurology, University Hospital, Ludwig Maximilian University of Munich.
“Persistent postural-perceptual dizziness (PPPD) is one of the most common causes of chronic vestibular disorders, with a substantial portion of the affected patients showing no significant improvement to standard therapies (i.e., pharmacotherapy, behavioral psychotherapy).
Patients with PPPD have been shown to have significant comorbidity with anxiety disorders and depression. Further, these patients show an activation of the autonomic nervous system resulting in symptoms such as nausea, an increase in heart rate, and sweating.
Based on the comorbidities and the activation of the autonomic nervous system, we addressed the question of whether non-invasive vagus nerve stimulation might be a treatment option for these patients.”
And this of course is one of the explanations we have been exploring as well. If you focused on the vagus nerve, can you successfully treat PPPD, nausea, an increase in heart rate, sweating, anxiety, depression, and other problems? What the researchers of this study suggested was:
In patients who had vagus nerve stimulation, who had previously not responded to the standard therapies of PPPD, showed that non-invasive vagus nerve stimulation significantly improved quality of life and depression, further the researchers reported less severe vertigo attacks/exacerbations, a decrease in total postural sway path as well as tendentious less anxiety occurred after stimulation. These data imply that short-term vagal nerve stimulation is a safe and promising treatment option in patients with otherwise refractory or non-responsive PPPD.
Vagus nerve stimulators at our center
In some cases, our patients are recommended to use a vagus nerve stimulator. This is not a primary treatment.
Vagus nerve stimulators are known to:
- Stimulate the nucleus tractus solitarius. What does this mean? The nucleus tractus solitarius are clusters of nerve cells that make up gray matter in the medulla oblongata (the lower part of the brainstem). In simple terms, this is what the nucleus tractus solitarius impacts:
- Facial, glossopharyngeal, and vagus nerve function including
- Taste. Please see my article Cranial Neuralgias – Symptoms of pain, smell, vision, hearing, taste, and talking
- Cardiovascular and respiratory function.
- Gastrointestinal system function.
- Decreased body pain.
- Increased sleep quality.
- Lessening severe depression and anxiety.
- Resolution of acute migraine and cluster headaches.
- Decreased tinnitus.
- Cervical Angina lessened.
- Dizziness, spatial awareness, balance improvements
- Facial, glossopharyngeal, and vagus nerve function including
Persistent Postural Perceptual Dizziness and vestibular rehabilitation therapy
In the above research much is discussed surrounding the idea of vestibular rehabilitation therapy. In other studies, a discussion of the effectiveness of the Cawthorne-Cooksey Exercise program for vestibular rehabilitation is discussed. In your medical journey, a physical therapist may have mentioned the Cawthorne-Cooksey exercises described exercises similar to those in this program.
The goal of the Cawthorne-Cooksey Exercise program is to:
- Get the neck and shoulder out of spasm by training the muscles to relax.
- Training the eyes with exercises to help them move independently of the head.
- Exercises and focus on good balance and posture
- Train yourself to be able to move your head in ways that previously caused disorientation and balance problems. Without these problems.
For some people, this type of therapy can be very effective. Certainly, someone with suspected cervical spine instability as the cause of their balance and dizziness problems could benefit. But what if these exercises are limited in their capacity to help but do not help at all? Should someone give up on the principles of strengthening the cervical spine? Or correcting posture or cervical spinal curvature?
The connection between cervical neck instability and neurologic and vascular type disorders
When we started our regenerative medicine practice back in 1993, one of the phenomena we studied in neck pain patients was, why did they have dizziness. Why did they have a lost sense of balance? Swaying? Visual hallucinations and strange sound sensations in their ears? Why did they have brain fog if they had no history of concussion? So for us, treating neck pain problems in patients with these other conditions and relating these conditions to their neck pain was not a new idea. But at the time, back in 1993, it was certainly something debated. Even today it is debated.
Is an answer to Persistent Postural Perceptual Dizziness to be found in damaged and weak cervical spine ligaments?
Above, I cited research that said 1 in 5 people in one particular study with Persistent postural-perceptual dizziness suffered from cervical dysfunction or neck problems. But where did neck problems of degenerative disc disease, cervical stenosis, herniated or compressed cranial nerves, jugular veins, and carotid arteries come from?
What are we seeing in this image?
A patient with severe cervical spine instability. Instability here is shown as a neck whose bones are out of place and a lost natural cervical spine curve. In the image, this person’s C1 (atlas) and C2 (axis) have floated some two inches to the front of the neck and from their normal optimal alignment. How did the C1 and C2 float away like this? Cervical spine ligaments hold the vertebrae in place and help maintain the neck’s normal curvature. When the neck ligaments are weak, damaged, or torn they can not hold the vertebrae where they are supposed to be, the vertebrae then float out of place. What happens when the vertebrae become hypermobile and float away? The nerves, veins, and arteries that are connected to these vertebrae themselves suffer from significant stretching and compression. This includes the spinal cord, the vagus nerve, and the superior cervical sympathetic ganglion. Among the many things, the superior cervical sympathetic ganglion and its nerve branches are responsible for our brain drainage, lymphatics, and blood supply. Please see my article Symptoms and conditions of Craniocervical and Cervical Instability.
The cervical ligaments are strong bands of tissues that attach one cervical vertebra to another. In this role, the cervical ligaments become the primary stabilizers of the neck. When the cervical ligaments are healthy, your head movement is healthy, pain-free, and non-damaging. When the ligaments are suffering from degenerative wear and tear or excessive looseness or laxity that prevents the ligaments from holding the vertebrae together, the ligaments lose their ability to control the proper motion of your head. The head begins to move in a destructive, degenerative manner on top of your neck.
The hunt for muscle pain, muscle spasms, and weakened neck muscles is the cause of Persistent Postural Perceptual Dizziness
Above we discussed the success some therapists had with Persistent Postural Perceptual Dizziness patients in helping their symptoms by getting the shoulder and neck muscles to relax.
- Chiropractic manipulation and physical therapy
- For the purpose of this article, we will address both of these treatment modalities as in essence they both seek the same goal. That is treating PPPD by putting the cervical spine back into proper anatomical alignment. Also, both may use intermittent traction and/or cervical collars.
- We should point out here that the goal of our treatments with regenerative medicine injections of dextrose and possibly blood platelets taken from the patient is the same. Putting the cervical spine back where it belongs. We may use intermittent traction and/or cervical collars. However, our treatments differ significantly as we seek more of a curative effect in a short window of treatments and not prolonged care.
- In chiropractic manipulation and physical therapy, there is an expectation that chiropractic will manipulate the cervical spine back into place and that physical therapy will strengthen the muscles of the cervical neck region to provide support.
- These treatments typically do not provide a long-term answer as we will see below because they must rely on strong cervical ligaments.
Regenerative Medicine Injections | Caring Cervical Realignment Therapy
Prolotherapy is an injection technique that stimulates the repair of unstable, torn or damaged ligaments. When the cervical ligaments are unstable, they allow for excessive movement of the vertebrae, which can then restrict blood flow to the brain, pinch on nerves (a pinched nerve causing vertigo), and cause other symptoms associated with joint instability, including cervical instability.
Non-surgical treatment – Cervical Spine Stability and Restoring Lordosis -Making a case for regeneration and repair of the spinal ligaments
Above we spoke about the vertebrae not being in the right place and this is caused by cervical spine ligament laxity or damage. The muscles of the neck may then spasm and thicken as a result of the muscle trying to do a job it was really not intended to do. Hold the cervical vertebrae in place. We also spoke about people who suffer dizziness when they move their heads a certain way.
Look at these images below. When the patient looks down, there is a 6 mm (about 2/10ths of an inch) space between the C1-C2. There is room for some vessels and nerves to get through. When the same patient looks up, 0 mm or NO SPACE. Everything in between gets pinched.
In this section, we are going to talk about realistic non-surgical options for the treatment of cervical spine instability and compressed cervical arteries and their related symptoms.
Treating cervical ligaments – published research from Caring Medical
Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult-to-treat musculoskeletal disorders including problems created by neck instability. Above, we discussed our 2014 research headed by Danielle R. Steilen-Matias, PA-C, (7) we also noted that when the cervical ligaments are injured, they become stretched out and loose. This allows for excessive abnormal movement of the cervical vertebrae.
- In the upper cervical spine (C0-C2), this can cause symptoms such as nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches.
Treating and stabilizing the cervical ligaments can alleviate the problems of cervical vertigo by preventing excessive abnormal vertebrae movement, the development or advancement of cervical osteoarthritis, and the myriad of problematic symptoms they cause.
Actual Prolotherapy treatment
This video jumps to 1:05 where the actual treatment begins.
This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.
Caring Cervical Realignment Therapy (CCRT)
As we discussed in reviewing the research above, our goal is to provide long-term solutions to the problems and symptoms of chronic neck pain and instability such as headaches, dizziness, vertigo, lightheadedness, imbalance, and a host of other symptoms attributed to neck injuries.
Caring Cervical Realignment Therapy combines individualized protocols to objectively document spinal instability, strengthen weakened ligament tissue that connects vertebrae, re-establish normal biomechanics and encourage the restoration of lordosis. This is our treatment method of moving towards putting a patient’s cervical spine back into place.
Through extensive research and patient data analysis, it became clear that in order for patients to obtain long-term cures (approximately 90% relief of symptoms) the re-establishment of some lordosis, (the natural cervical spinal curve) in their cervical spine is necessary. Once spinal stabilization was achieved with Prolotherapy and the normalization of cervical forces by restoring some lordosis, lasting relief of symptoms was highly probable.
The Horrific Progression of Neck Degeneration with Unresolved Cervical Instability. Cervical instability is a progressive disorder causing a normal lordotic curve to end up as an “S” or “Snake” curve with crippling degeneration.
Treatments for cervical spine realignment – restoring the curve without surgery
When we start looking at the most recent research papers surrounding treatments for cervical spine realignment, we often find ourselves reading a lot of new research on cervical spine surgery procedures. Non-surgical treatments for cervical spine realignment are, for the most part, fewer and far between. There is a rush in medicine to surgically correct cervical spine abnormalities including the loss of the natural cervical spine curve. In our office, we rush more to non-surgical applications to help patients with cervical spine instability and abnormal curvature of the spine. But what if you were told surgery should be strongly considered?
Summary and contact us. Can we help you? How do I know if I’m a good candidate?
We hope you found this article informative and that it helped answer many of the questions you may have surrounding Persistent Postural Perceptual Dizziness. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.
Contact the Hauser Neck Center team
1 Li L, He S, Liu H, Pan M, Dai F. Potential risk factors of persistent postural-perceptual dizziness: a pilot study. Journal of neurology. 2021 Nov 20:1-1. [Google Scholar]
2 Bittar RS, von Söhsten Lins EM. Clinical characteristics of patients with persistent postural-perceptual dizziness. Brazilian journal of otorhinolaryngology. 2015 May 1;81(3):276-82. [Google Scholar]
3 Herdman D, Evetovits A, Donkin Everton H, Murdin L. Is ‘persistent postural perceptual dizziness’a helpful diagnostic label? A qualitative exploratory study. Journal of Vestibular Research. 2020 Dec 2(Preprint):1-1. [Google Scholar]
4 Axer H, Finn S, Wassermann A, Guntinas‐Lichius O, Klingner CM, Witte OW. Multimodal treatment of persistent postural–perceptual dizziness. Brain and Behavior. 2020 Dec;10(12):e01864. [Google Scholar]
5 Popkirov S, Staab JP, Stone J. Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness. Practical neurology. 2018 Feb 1;18(1):5-13. [Google Scholar]
6 Sun L, Xiang K. A review on the alterations in the brain of persistent postural-perceptual dizziness patients and non-pharmacological interventions for its management. Reviews in the Neurosciences. 2020 Aug 27;31(6):675-80. [Google Scholar]
7 Eren OE, Filippopulos F, Sönmez K, Möhwald K, Straube A, Schöberl F. Non-invasive vagus nerve stimulation significantly improves quality of life in patients with persistent postural-perceptual dizziness. Journal of neurology. 2018 Oct;265(1):63-9. [Google Scholar]
8 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326. [Google Scholar]
9 Hashimoto K, Takeuchi T, Ueno T, Suka S, Hiiragi M, Yamada M, Koyama A, Nakamura Y, Miyakoda J, Hashizume M. Effect of central sensitization on dizziness-related symptoms of persistent postural-perceptual dizziness. BioPsychoSocial Medicine. 2022 Dec;16(1):1-7. [Google Scholar]
10 Knight B, Bermudez F, Shermetaro C. Persistent Postural-Perceptual Dizziness. InStatPearls [Internet] 2022 Jan 27. StatPearls Publishing. [Google Scholar]
11 Staab JP, Ruckenstein MJ, Solomon D, Shepard NT. Serotonin reuptake inhibitors for dizziness with psychiatric symptoms. Archives of Otolaryngology–Head & Neck Surgery. 2002 May 1;128(5):554-60. [Google Scholar]