Treatment option: Dry needling for dizziness
Reseting the proprioceptive system
A hidden source of dizziness and disequilibrium: the cervical spine (neck)
Dizziness is one of the most common complaints of people suffering from post-concussive syndrome. Some may assume it is caused entirely by an injury to the brain, or to the inner ear, or perhaps to the oculomotor system. But there’s a fourth area of injury and dysfunction that often goes ignored—the neck.
Dizziness can be caused (alone or in combination with injuries to the areas mentioned above) by injury and dysfunction within one’s neck. The neck houses the cervical spine, so this form of dizziness is called cervicogenic dizziness. The feeling is one of disequilibrium rather than vertigo (vertigo implicates other systems, in which case one’s neck may, or may not, be a contributing factor).
One of the main culprits in this form of dizziness is something called cervical joint position error, which effectively means your brain is receiving faulty information from your cervical spine about where your head and neck are in space. This faulty proprioceptive information conflicts with signals coming from other areas of your balance system, putting a strain on the parts of your brain that integrate and process this incoming information.
The problem with leaving your neck to a chiropractor
Too often, cervicogenic dizziness can go completely unnoticed and untreated within a substandard concussion protocol. If the neck is mentioned at all, it’s often by a chiropractor outside the mainstream medical system that may be treating your other post-concussion symptoms.
This places your neck in a “parallel universe” of treatment where there is no integration with the other modes of treatment you’re receiving. For example, someone might be receiving vision therapy, but since there’s such a tight neurological integration between the upper cervical area and the vision system, their progress may be slow until the dysfunctions in the neck are addressed.
Fun test: Gently place your fingertips on the back of your upper neck, keep your head still, and merely move your eyes to the left or right—you should feel the sub-occipital muscles in your neck fire a little in response to your eye movements. That’s how neurologically integrated your neck is with your vision.
Chiropractic treatment, with its focus on joint manipulation, will not fully address soft tissue dysfunctions in the neck. It could even worsen the problem, especially if the treatment involves rapid movement of the head and neck (which is one reason why I’m a fan of atlas orthogonal chiropractic, which doesn’t employ such movements).
Pathways for treating cervicogenic dizziness
Apart from atlas orthogonal chiropractic, I know of two other avenues for giving one’s neck the care it deserves.
The first is manual cervical joint manipulation therapy and functional training from a doctor of physical therapy—ideally one with experience in treating cervicogenic dizziness.
You might think “manual cervical joint manipulation therapy” sounds a lot like chiropractic, but the two aren’t the same. The focus of the former is on re-establishing your own internal locus of control over your neck, including your range of motion. It also tees up rehabilitative exercises that will help you functionally strengthen your neck (something chiropractic care may not do). If you’re interesting in this therapy, use the current clinical practice guidelines for PT as a reference.
Manual therapy can be even more effective when combined with something called dry needling, which is similar to acupuncture. Let’s look at the evidence for its efficacy.
The case for dry needling
I first learned about dry needling while I was reviewing the published work of Dr. Julia Treleaven, a researcher at the University of Queensland.
One of the things that makes her work compelling is that she began her career in the area of whiplash injury treatment, which allowed her to uncover connections between two related mechanisms of injury: whiplash and concussion.
Dr. Treleaven has since developed and refined specific approaches to identifying the sources of balance dysfunction, be they central, peripheral, oculomotor—or cervical. (Incidentally, one of her more well known quotes is: “A concussion is not a diagnosis, it is a mechanism of injury.”) She has authored or co-authored over 100 journal articles, including this one:
Mentioned in that title, the obliquus capitis inferior is a muscle in the upper cervical area of your neck, in a group of (sub-occipital) muscles linking the back of your head (including the occiput) to the back of your neck. It’s the only sub-occipital muscle that does not attach to the skull.
Here are a few choice quotes from the article:
A single session of dry needling of the obliquus capitis inferior reduces cervical joint position error in people with neck pain.
The upper cervical spine and particularly the obliquus capitis inferior (OCI) play an important proprioceptive role; and its impairment may alter cervical sensorimotor control. Dry needling (DN) is a valid technique to target the OCI.
Cervical joint position error (JPE), cervical movement sense, standing balance and oculomotor control were examined at baseline, immediately post-intervention, and at one-week follow-up.
The results from the current study suggest that a single session of DN of the OCI reduces JPE deficits and increases upper cervical mobility in patients with neck pain.
This is a useful takeaway from one patient in the study:
Importantly, although DN did not fully resolve the dizziness in the 36-year-old patient, the treatment was still useful. The use of DN implicated the cervical spine musculature as a possible component of the patient’s dizziness, which led to appropriate treatment strategies. In addition to traditional vestibular and balance rehabilitation, the patient also received skilled manual therapy & exercise targeting the cervical spine.
And finally:
Patients reported a significant reduction in their dizziness, suggesting that DN with mechanical stimulation may have disrupted the aberrant feedback and helped reset the proprioceptive system.
So: In this study, dry needling was done in conjunction with manual joint manipulation therapy, performed by a skilled physical therapist. And: While the dizziness in some patients wasn’t eliminated, it was significantly reduced, allowing them to make progress with other forms of therapy.
Where to get dry needling
Depending on where you live (regulations vary by state in the US) you can receive dry needling from a doctor of physical therapy (who can also treat your neck manually and help you regain functional strength), or from an acupuncturist who’s completed additional training in dry needling.
Although Dr. Trelevean reported positive results for patients who received a single session of dry needling, a dry needling practitioner will likely recommend about five treatments, each session done about 72 hours apart.
If the dry needling practitioner isn’t your physical therapist, you may want to synchronize PT appointments (for manual neck joint manipulation therapy and exercise) on the same day as dry needling. Consult with your providers.
Wrapping up
The neck is an often overlooked source of dizziness. The symptoms of whiplash and concussion have tremendous overlap, including dizziness. The treatment of one’s neck should be integrated with other forms of therapy, including vision and vestibular. A skilled and properly trained physical therapist can assess the presence of cervicogenic dizziness.
Combined with manual therapy, dry needling can help remedy cervicogenic dizziness. In various studies, including one by Dr. Julia Treleaven, it was found to reduce joint position error and increase upper cervical mobility. Importantly, it also helped identify the cervical spine as a source of dizziness, which led to further appropriate treatment, including rehabilitative exercises targeting the cervical spine.
Even though the patients in the study only received one session, a dry needling practitioner is likely to suggest around five treatments before the results really sink in. Depending on the regulatory environment where you live, dry needling may be available from your physical therapist, or from an acupuncturist.
Brainwave is an informational resource for people whose symptoms haven’t resolved after a concussion or mTBI. I endeavor to present this information in a clear and concise way, spelling out what’s backed by science and what remains unknown. Nothing here is meant as a substitute for professional medical advice, diagnosis, or treatment. I am not a physician or a healthcare practitioner of any kind; I’ve simply had a lot of sports-related concussions and had to learn this stuff the hard way. If you found this information helpful or know someone who might benefit from it, please share and subscribe to Brainwave.