Developed for OUCOM CORE By: Derek Stone, D.O.

1. Osteopathic Approach to Vertigo Developed for OUCOM CORE By: Derek Stone, D.O. Edited by: David Eland, D.O. and the CORE Osteopathic Principles and Practices Committee Session #10 – Series B

2. Objectives • Review signs and symptoms of vertigo • Discuss somatic dysfunction related to vertigo • Review osteopathy in the cranial field • Review specific cranial techniques for treating vertigo

3. CC: 28 y/o with c/o room spinning for 30 min after rolling over in bed. Hx CC: Started all of a sudden, no history of trauma. Occurred for two mornings in a row after rolling over in bed. Room spinning sensation for 30-45 sec. Went away on own. Nausea, no vomiting. Never had it before, did not really bother him once out of bed. No hearing loss or tinnitus with it. Clinical Case

4. PE: CN II-XII intact. Hearing intact. No nystagmus. PERRLA. Turbinated clear without discharge. Pharynx clear. No carotid bruits. + Dix-Hallpike maneuver. Osteopathic: OA FRS left. Increased suboccipital tension. C4 FRS right. CRI at 12 cycles/min with amplitude of 3/5. Right temporal internally rotated. Clinical Case

5. This figure illustrates the Dix-Hallpike test for BPPV: A person is brought from sitting to a supine position, with the head turned 45 degrees to one side and extended about 20 degrees backward. Once supine, the eyes are typically observed for about 30 seconds. If no nystagmus ensues, the person is brought back to sitting. There is a delay of about 30 seconds again, and then the other side is tested. Dix-Hallpike Test1 of 2 T. Hain, M.D. web-site

6. When doing the Dix-Hallpike on a flat table, it is often helpful to place a flat "boat" cushion under the persons back, to obtain head extension. If the person has arthritis in their neck, the maneuver may be performed in side-lying position. 2 of 2 T. Hain, M.D. web-site

7. Most common cause of peripheral vertigo Calcium crystals displaced within semicircular canal Episodic vertigo lasting for seconds, associated with change in head position DX by Dix Hall-Pike test Treatment with repositioning exercises, vestibular suppressants (meclizine), MT Typically self limiting Benign Paroxysmal Positional Vertigo

8. Internal rotation of temporal bone CN VIII SBS strain patterns Cervical musculature tension OA and cervical somatic dysfunction T1-T5 somatic dysfunction Sympathetic output to head and neck Somatic Dysfunction common in Vertigo

9. Sutherland’s theory of cranial motion termed the Primary Respiratory Mechanism Inherent motility of brain and spinal cord Fluctuation of CSF Intracranial and intraspinal membranes act as a reciprocal tension membrane Articular mobility of the cranial bones Involuntary mobility of the sacrum between the ilia Osteopathy in the Cranial Field

10. Cranial Rhythmic Impulse (CRI) Palpable wave like expansion and contraction of the head Flexion and extension of midline bones (sphenoid and occiput) Internal and External rotation of paired bones (parietals and temporal) Rate- 10-14 cycles per min Amplitude Perceived distance from maximal flexion to maximal extension (0-5 scale) Symmetry Osteopathy in theCranial Field

11. SBS is considered the driving force of the CRI Tension or trauma can restrict motion of the SBS and lead to strain patterns Torsion Sidebending Rotation Vertical Lateral Compression Osteopathy in the Cranial Field(Sphenobasilar Synchondrosis)

12. Temporal Bone Anatomy • Temporal bones externally rotates with craniosacral flexion • Common dysfunction in vertigo • Articulates with sphenoid, occiput, parietals, zygoma, and mandible

13. Temporal Decompression Parietal Lift CV4 V-Spread for OA Temporal Rocking Lab TechniquesCranial

14. Vault HoldsReview

15. Temporal Decompression • Used to correct restricted temporal bone mobility • Gently pull earlobes in a posterolateral direction until slight give is equal on both sides • Recheck

16. Parietal Lift • Can be used to free up motion of temporal bone • Gently contact parietals superior to squamous suture • Gently press medially and gently lift parietals superiorly until give is equal on both sides

17. CV4 • Thenar eminences on occipital bone medial to occipitomastoid sutures • Palpate cranial flexion and extension • Gently encourage extension and resist flexion until CRI stops • Maintain this extension still point until CRI returns, typically at a greater amplitude

18. V-SpreadOccipita-mastoid Suture • Contact bone on either side of suture with index and middle finger and apply steady traction to separate suture • Place index and middle finger of other hand on opposite side of the head and exert slight repetitive impulse toward restricted suture • Continue sutural traction and contralateral impulse until give is finished

19. Temporal Rocking • One hand exaggerates left temporal in flexion (external rotation of the temporal) and the other hand dampens right temporal into extension (internal rotation of the temporal) • The process is reversed • Can reach a still point • Return of CRI results in improved temporal bone motion

20. TreatmentCase Study • Pt given meclizine for acute attacks of vertigo • Repositioning exercises performed in office and • taught to patient • OMT provided • Suboccipital inhibition • ME to cervicals • Temporal decompression • CV4

21. Suboccipital Inhibition • Hold occiput in palms and align fingertips inferior to inion • Straighten fingers to press fingertips into muscles • Hold until relaxation and head drops into palms

22. ME for OA • Place OA at direct barrier • Ask patient to side bend gently away from the restriction against your resistance for 3-5 seconds • Repeat 3-5 times, each time moving to new restriction barrier

23. Temporal Decompression • Used to correct restricted temporal bone mobility • Gently pull earlobes in a posterolateral direction until slight give is equal on both sides • Recheck

24. CV4 • Thenar eminences on occipital bone medial to occipitomastoid sutures • Palpate cranial flexion and extension • Gently encourage extension and resist flexion until CRI stops • Maintain this extension still point until CRI returns, typically at a greater amplitude

25. Vertigo is a common condition that lends itself to treatment with OMT Temporal bone and cervical somatic dysfunction are commonly implicated Often one temporal in internally rotated and the other externally rotated. Knowledge of some basic cranial techniques can be helpful in treating vertigo Conclusion

26. Essig-Beatty, D.R. Pocket Manual of OMT. Lippincott Williams and Wilkins, Philadelphia. 2004 Wales, Annie. Basic Course in Osteopathy in the Cranial Field. The Cranial Academy. Rancho Mirage, CA; 2001 Magoun, Harold Jr. Osteopathy in the Cranial Field. Second Ed. References

27. Dix-Hallpike - reference