Summary
Dizziness and loss of balance are common impairments, often poorly treated. If you have these impairments and have tried treatment with no success, don’t worry, there is hope. One of the most common causes of dizziness is completely unknown to the majority of medical professionals: Muscle and joint pathology. Muscle and joint pathology can cause severe dizziness that mimics vertigo-like symptoms, seasickness, loss of balance, etc., via autonomic nervous system dysregulation. If you have patients with any of these types of symptoms, or if you have any of these symptoms yourself, and have tried treatment with little success without trying dry needling and manipulation, this article will help.

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Dizziness and loss of balance (LOB) is a common impairment associated with all sorts of things:

• Medication side effects
• Bad food
• Good alcohol
• Ear, brain, + eye problems
• Viruses
• Bacteria

The list goes on. A lot of things can cause dizziness and/or LOB. Muscles, however, are rarely thought of as a potential cause of dizziness. This is a huge mistake. It is the reason so many people needlessly suffer dizziness throughout life. Have you been to a bunch of different doctors trying to figure out why you are dizzy with little to no success? Oftentimes, this is because your dizziness and/or LOB is stemming from muscle and joint pathology, typically in the cervicothoracic spine. Unless this is addressed, the sympathetic portion of the autonomic nervous system remains hyperactive, leading to homeostatic dysregulation throughout the body, which causes many impairments, including dizziness and LOB.

The cervicothoracic spine + dizziness

Although pathologic musculature anywhere in the body can lead to dizziness and/or LOB, for simplicity, let’s stick to the cervicothoracic spine for now. There are about 16 muscles that attach on the back of your head. In a physical therapy setting, pathology in any of these muscles, or combination of muscles, is the most common cause of dizziness. Remember, 7 or so of these muscles travel all the way from the base of the skull to the tailbone. If you have tight, pathologic muscles, your joints are also pathologic. Remember, joints don’t move themselves, muscles move them, and tight muscles crossing joints is one of the worst things for joint health. Joints get compressed, the synovial tissue stops producing adequate amounts of synovial fluid, cartilage gets smushed, blood flow slows down, and on it goes. You may be aware you have some neck or back issues, but you may not. Pain is not necessary to cause dizziness. What is necessary is having enough abnormal afferent signals going from your cervicothoracic spine to your brain to reach the individual threshold to systemically disrupt homeostasis, thus causing dizziness.

There is a nucleus in the dorsal horn of the spinal column called the trigeminocervical nucleus. This nucleus has reciprocal connections with vestibular (ear) nuclei. It is also close to where the afferent nerve impulses from our cervicothoracic muscles cross the spine. The current hypothesis on how this happens is just that—a hypothesis. We know so little about how all this works, which makes it super exciting because knowing everything would be so boring. Anyway, the current thought is that with enough negative afferent electrical signals traveling from the spine to the brain, something in the spinal column and brain gets short circuited and the trigeminocervical nucleus begins to malfunction. When this happens, what our eyes are seeing becomes unconsciously disjointed from what our ears are telling our brain. This causes dizziness, LOB and a lot of other uncomfortable side effects.

What about BPPV + dizziness?

Note: BPPV is, without question, the most common diagnoses for dizziness in PT land. It is not the most common cause, and it should not be the most common diagnosis, but more on that in a bit. BPPV is the ear problem where the little otoliths (think of them as pebbles) get dislodged from their storage chamber in the ear and begin floating around the ear canals. Most people have 3 canals on each side. These canals are filled with fluid, and the inside of each canal has tiny little tentacle-like things attached to it, waving in the fluid that fills the canals like sea grass waving in the ocean as the tide changes. Typically, the little pebbles are all stored in the central chamber inside the ear. If the pebbles get dislodged from their home, they begin floating around the canals with the tentacles. Each time a pebble hits a tentacle, it sends an electric signal to the brain telling us that we are moving in a certain direction based on how the pebble hits it. These paradoxical signals are confusing, typically causing that uncomfortable, nauseous feeling everyone has had at one time or another.

When this happens, people stop moving their head in certain directions because the little pebbles start to hit the tentacles in the ear tubes, making them dizzy. When people are worried about moving their neck and head normally, muscles and joints get stiff. Joint capsules create the synovial fluid in our joints, and synovial fluid is the oil for our joints. Without joint capsule movement, the tissues stop producing the synovial fluid our joints need, which is like driving a car around with old, gritty, sludgy oil in the engine. This is not good…and this compounds the dizziness problem, especially over time. Even if the original cause of the dizziness was pure BPPV, if it is chronic, the cervical structures often get aggravated enough to start sending lots of negative afferents to the brain, which can also cause dizziness. This becomes a negative feedback loop.

In my clinical experience, pure BPPV is significantly less common than pure cervicogenic dizziness. The two may present together, especially if the dizziness is chronic and started as an ear problem, but cervicogenic dizziness is more common than BPPV. The easiest way to figure out what is going on is to assume the dizziness is coming from the ears. If you are competent at assessing the canals and performing the proper corrective maneuver, if indicated, there is about a 90% chance of complete resolution of symptoms after 1 treatment. If the symptoms are untouched, or only improve a bit, you can assume something other than the ear is causing or helping to cause the dizziness, most often the cervicothoracic musculature and joints.

Our eyes and ears are the 2 primary ways we maintain balance, and both of these systems need to be working together to give our brain the information necessary for us to keep our balance and to keep us from getting dizzy. If the eyes and ears begin sending the brain conflicting information, the result is dizziness, nausea, LOB, etc. Have you ever been in a stationary car, then looked at a car next to you that’s moving, but it tricks you for a second into believing that you are the one moving? Like, WTF, did I forget to put it in park? Are aliens abducting me? Have I entered an alternate dimension?

When this happens to me, I get a tiny bit nauseous for a second until I realize what is going on. This happens because, for a moment, your eyes are telling your brain you are moving, but your ears are telling your brain you are stationary. These conflicting signals cause varying degrees of dizziness. This is the same reason some people get dizzy in I-max theaters. Your ears know you are not moving, but your eyes tell your brain you are moving. Stupid, dumb-dumb eyes. Ha, ha.

So, let’s assume we have a patient who is dizzy. It randomly started a few years ago and has gotten worse over time. Has had brain scans, tried medicine for Meniere’s Disease, and has been to vestibular specialists. The ears have been cleared and are not an issue. There are no other known issues aside from hypomobility of the cervicothoracic spine with muscular and joint discomfort upon palpation. Sometimes the neck and back are painful, sometimes not. The dizziness gets worse with certain head movements. None of the things they have tried for their dizziness has made a significant difference. Nobody had assessed or addressed their cervicothoracic musculature and spine as a potential cause of their dizziness.

Note: If this describes you to some degree or other, there is a high likelihood you are suffering from cervicogenic dizziness. If you are, it is quite possible to needlessly suffer this dizziness for life, as many people do, unless someone with specific knowledge addresses your muscles and joints with the proper combination of dry needling and manipulation. Unfortunately, there are very few people in the USA who understand how to treat this way. However, never fear!!! At Intricate Art Spine & Body Solutions, we can teach you how to fix this or point you in the direction of someone we have trained. No worries. We can help. I am also really good with fly fishing instruction and entomology and random animal facts, if anyone has need of my other skills….

Now, at the end of the day, cervicothoracic muscles do not directly cause dizziness. They indirectly cause dizziness via disruption of our nervous systems, specifically, the autonomic nervous system (ANS). If we have conflicting signals going from our eyes and ears to our brain, things get all jumbled up, and we get dizzy, nauseous, lose balance, etc. Typically, people experience dizziness in a couple of general ways. The question I usually ask is, “Does it feel like you are on a boat, or do you feel like the room is spinning, or both?” This can help to indicate if the vestibular ocular reflex (VOR, part of the ANS) is a problem secondary to muscle and joint pathology, or if the ear canals are a problem, or both. VOR dysfunction typically presents with a feeling of being on a boat in the waves. BPPV typically presents as the room spinning. Remember, this is in general. Pure cervicogenic dizziness can 100% mimic pure BPPV. Sneaky little muscles!

Dry needling the cervicothoracic musculature to treat dizziness

Dry needling the cervicothoracic musculature, in combination with spinal manipulation, is essential to fully resolving just about any case of dizziness. Again, it often doesn’t matter why you were dizzy in the first place. If you have been that way for any significant period of time, your muscles and joints are going to be problematic. Remember, tight, pissed off muscles and joints, even if they do not hurt a lot, can cause severe dizziness, brain fog, mental disturbances, headaches, sleeping problems, etc. Needling, in combination with manipulation, is the best way I know how, and I think the best way that currently exists, to quickly and effectively eliminate signs and symptoms of cervicogenic dizziness.

It is sometimes impossible to tell if the cervicothoracic muscular caused ANS imbalance and dizziness, or if ANS imbalance and dizziness lead to the muscular and joint issues. It really doesn’t matter much of the time. If the condition is at all chronic, the muscles and nervous systems need to be treated concomitantly in order to achieve maximal resolution of the causative factors of dizziness. Even if the muscles are not the sole cause of the dizziness, the dizziness will never be fully resolved until the muscles and the ANS are specifically targeted and regulated.

Note: If you are being treated, or if you are treating someone, it is common for the dizziness to get worse for the first few treatments. Don’t worry though, this is a good sign! Trust me, I didn’t go to school just to eat my lunch…there was recess as well… The sympathetic portion of the ANS is already hyperactive and hypersensitive in people with cervicogenic dizziness. In a healthy nervous system, needling initially causes the SANS to elevate for a time before it drops below baseline and the PANS takes over, leading to ANS homeostasis. Remember, cervicogenic dizziness stems from SANS hyperactivity. With a dysfunctional ANS already in severe sympathetic hyperactivity, the dramatic alterations of the nervous system toward homeostasis, caused by needling and manipulation, can make things worse initially. Although things are changing toward homeostasis, which is good, the dramatic change causes some adverse signs and symptoms in some people. If this happens, you can now be certain that the cervicothoracic structures are, at least, a part of the problem. So don’t get discouraged if this happens and don’t stop treatment. You are on the correct path to recovery!

Remember…

Dizziness and loss of balance are common problems people have, but they are often poorly treated.

If you have these or similar symptoms and have tried treatment with little success but have not tried the combination of dry needling and manipulation, you are in luck.

Tight muscles and joints are not typically thought of as causative factors of these symptoms, but they are actually one of the most common causes. This is easily fixable.

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