Osteopathy & Vertigo

Osteopathy and Vertigo: Science, Myths, and Reality

Vertigo, characterized by a sensation of spinning or unsteadiness, affects approximately 20% of adults. Its origins are diverse, encompassing inner ear disorders (e.g., benign paroxysmal positional vertigo [BPPV], Ménière's disease), neurological conditions (e.g., vestibular migraines), and musculoskeletal imbalances (e.g., cervicogenic vertigo). Given these multifactorial causes, osteopathy offers a manual approach aimed at correcting cervical, cranial, or postural dysfunctions that might disrupt the vestibular system. This article examines the scientific evidence supporting its efficacy, the physiological mechanisms proposed, and the ongoing controversies surrounding this practice.

Types of Vertigo and the Osteopathic Approach

Main Causes

• Benign Paroxysmal Positional Vertigo (BPPV): Caused by dislodged calcium carbonate crystals (otoliths) within the inner ear.

• Cervicogenic Vertigo: Linked to neck tensions or trauma (e.g., whiplash injury).

• Vestibular Migraines: Vertigo occurring as a symptom of migraine attacks.

• Ménière's Disease: An inner ear disorder characterized by episodes of vertigo, tinnitus, and hearing loss.

Osteopathic Strategies

Osteopathic strategies for vertigo typically involve:

• Cervical Manipulation and Mobilization: Designed to release restricted vertebral joints and alleviate nerve irritation.

• Postural Work: Addressing muscular or fascial imbalances that affect overall balance.

Review of Scientific Studies

Cervicogenic Vertigo

• Encouraging Data: A 2019 randomized study published in the Journal of Manual & Manipulative Therapy compared osteopathy to rehabilitation exercises in 80 patients with post-traumatic vertigo. The osteopathic group showed a 45% reduction in vertigo intensity, significantly higher than the 25% reduction in the control group.

• Proposed Mechanisms: It's hypothesized that cervical manipulations enhance proprioception and reduce vertebral artery compression, as suggested by a Doppler ultrasound study in Clinical Biomechanics (2020).

BPPV (Benign Paroxysmal Positional Vertigo)

• Limited Effectiveness: The established treatment for BPPV is the Epley maneuver (otolith repositioning). A 2021 meta-analysis in Otology & Neurotology, encompassing 15 trials, concluded that osteopathy provides no additional benefit when used alongside the Epley maneuver.

• Isolated Cases: While some case reports describe reduced recurrences after craniosacral therapy, these observations lack statistical validation.

Vestibular Migraines

• Modest Effects: A 2020 controlled trial in Headache observed a 30% decrease in attack frequency in patients treated with cranial osteopathy, compared to a 15% decrease in the placebo group. However, the study involved a small sample size ($n=60$), and the results have not been replicated.

Ménière's Disease

• No Evidence: There are no rigorous studies to support the use of osteopathy for Ménière's disease. Existing publications are limited to anecdotal testimonies.

Debunking the Mythes of Osteopathy and Vertigo

To navigate the treatment landscape safely, it is essential to distinguish between clinical possibilities and common myths:

• Myth 1: "Osteopathy can 'fix' BPPV by moving the crystals."

  • Reality: While osteopaths may be trained in the Epley maneuver, traditional "osteopathic adjustments" or spinal manipulations do not move otoliths. Only specific repositioning maneuvers (canalith repositioning) are effective for BPPV.

• Myth 2: "Craniosacral therapy can move the bones of the skull to drain the inner ear."

  • Reality: Scientific evidence shows that cranial sutures in adults are fused or extremely rigid; manual pressure cannot "move" these bones to physically drain fluid from the inner ear.

• Myth 3: "All vertigo comes from a 'misaligned' neck vertebra."

  • Reality: The concept of a "subluxation" or bone being "out of place" is an outdated model. Vertigo is more often related to the input the brain receives from neck muscles (proprioception) or inner ear signals, rather than a bone being physically misaligned.

• Myth 4: "One session will permanently cure vertigo."

  • Reality: While acute cervicogenic vertigo may see rapid improvement, most vestibular issues require a multidisciplinary approach, including exercises and time for neurological compensation.

• Myth 5: "Osteopathy is a substitute for an ENT consultation."

  • Reality: Vertigo can be a symptom of serious underlying conditions (tumors, strokes, or infections). An ENT or Neurologist diagnosis is essential before seeking manual therapy.

Physiological Mechanisms: Hypotheses and Controversies

• Improved Vertebrobasilar Circulation: Cervical manipulations are thought to alleviate restrictions on vertebral arteries, thereby optimizing blood supply to the brainstem and inner ear.

• Normalization of Cervical Proprioception: Manual techniques are believed to correct dysfunctions in the neck's joint sensors, which play a crucial role in maintaining balance.

• Autonomic Nervous System Modulation: Cranial osteopathic techniques are hypothesized to influence the vagus nerve, potentially reducing stress and vestibular symptoms.

Scientific Criticisms:

• The actual mobility of vertebral arteries during manipulations has not been demonstrated by medical imaging.

• The precise link between cervical dysfunctions and vertigo remains unclear, lacking objective biomarkers.

• The placebo effect, enhanced by therapeutic interaction, could account for some reported improvements.

Risks and Safety

Cervical manipulations, particularly forced rotation, carry a rare but serious risk:

• Vertebral Artery Dissection: This severe complication can lead to a stroke (estimated incidence: 1 case per 500,000 to 1 million manipulations).

• Temporary Worsening of Vertigo or Nausea.

Absolute contraindications:

• Vertebral instability (e.g., due to rheumatoid arthritis).

• History of stroke.

• Focal neurological signs (e.g., speech disorders).

Comparison with Other Treatments

• Vestibular Rehabilitation: This approach is well-validated for chronic vertigo (Level A evidence) and often surpasses osteopathy in effectiveness.

• Medications: Useful for acute episodes but do not address mechanical causes.

• Acupuncture: Some studies suggest similar results to osteopathy, implying a shared contribution from the therapeutic context effect.

Position of Medical Authorities

• American Academy of Neurology (AAN): Does not recommend osteopathy as a first-line treatment for vertigo.

• French Society of ENT: Favors repositioning maneuvers for BPPV and vestibular rehabilitation for chronic vertigo.

Osteopathy shows promising results in the management of cervicogenic vertigo, where musculoskeletal dysfunctions play a key role. However, its effectiveness remains uncertain for vertigo of purely vestibular origin. Pending more robust data, osteopathy should be considered an adjuvant therapy, integrated with vestibular rehabilitation and specialized medical follow-up.

Alain Guierre

Key References:

• Reid, S. A. et al. (2019). Osteopathic Manipulative Therapy for Cervicogenic Dizziness. Journal of Manual & Manipulative Therapy.

• Hilton, M. P. et al. (2021). The Epley Maneuver for Benign Paroxysmal Positional Vertigo. Otology & Neurotology.