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RESEARCH LIBRARY - DOCUMENT [34]

Category: Scientific Studies

Date	10-mar-2003
Title	Cervical Signs and Symptoms in Patients with Meniere’s Disease: A Controlled Study
Author	Assar Bjorne, D.D.S.; Agneta Berven, Physiotherapist; Göran Agerberg, D.D.S., Odont. Dr., Ph. D.
Main Condition/ Disease	Hearing Disorders – Meniere’s Disease
Source	The Journal of Craniomandibular Practice July 1998, Vol 16, NO. 3, CHROMA Inc.
Abstract	As quoted: “This study compares the frequency of signs and symptoms from the cervical spine in 24 patients diagnosed with Meniere’s Disease and 24 control subjects from a population sample. From previous controlled comparative study concerning signs and symptoms in craniomandibular disorders, 24 patients diagnosed with Meniere’s Disease (10 males and 14 females) and their 24 matched control subjects participated in this investigation on the state of the cervical spine. Symptoms of cervical spine disorders, such as head and neck/shoulder pain, were all significantly more frequent in the patient group than in the control group. Most of the patients (75%) reported a strong association between head neck movements in the atlanto-occipital and atlanto-axial and triggered attacks of vertigo. Also, 29% of the patients could influence their tinnitus by mandibular movements. Signs of cervical spine disorders, such as limitations in side-bending and rotation movements, were significantly more frequent in the patient group than the control group. Tenderness to palpation of the transverse processes of the atlas and the axis, the upper and middle trapezius, and the levator scapulae muscle were also significantly more frequent in the patient group. The study shows a much higher prevalence of signs and symptoms of cervical spine disorders in patients diagnosed with Meniere’s disease compared with control subjects from the general population.”
Summary	Bjorne was kind enough to forward me his paper, after I found a reference to it on a website. His paper I consider confirms that dysfunction or disorders of the cervical spine highly correlate with conditions or symptoms like TMJ syndrome, dizziness, vertigo, ear fullness, hearing loss and tinnitus. There are many other papers, which also point to cervical spine disorders or abnormalities being associated with these conditions/symptoms and many other symptoms. Bjorne et al describe Meniere’s disease (MD) as exhibiting “a classic symptom triad consisting of vertigo, fluctuating hearing loss and tinnitus” and in the past has been diagnosed as “dizziness of unknown origin” [2]. In Sweden alone it is estimated that “between 40,000 and 50,000 people suffer from MD” symptoms occasionally, which implies “large costs to both the individuals and society”. Extrapolating this to World figures would be an interesting exercise. I also think that in many cases patients exhibit some symptoms of MD but never really ‘full blown’ MD and thus are not included in the figures. Studies have revealed some patients having “gross dilatation of the endolymphatic system” which has been described as “endolymphatic hydrops” or EH. Most ENT doctors today seem caught up in the EH theory as being a cause of MD and treatment modalities are targeted towards EH, but I think this must surely ignore the fact that overwhelmingly people who are diagnosed with MD exhibit cervical spine dysfunction.In controlled studies, where one group is the patient group and the other the control group, Bjorne et al revealed a consistency in some of the responses and findings in people with MD as compared to the control group. They found that the MD patient group has significantly more signs and symptoms of craniomandibular disorders (CMD) and also there were more likely to have complaints which pointed to cervical spine disorders (CSD), such as neck pain and tenderness, loss of range of motion (ROM), palpation tenderness on the transverse processes of the atlas than those in the control group. About “33% of the patients reported their vertigo could be triggered in ordinary situations when they shifted their posture”… “29% described ordinary situations such as going up or down a staircase, climbing a ladder, turning their head while confined to bed”..etc.“During periods of more frequent vertigo attacks, 18 (75%) of patients reported that they could trigger attacks of vertigo by extension, flexion or side-rotation of the head and neck”. Bjorne states further “the dominant findings at the clinical examinations were the differences between the patients and the control subjects according to tenderness and palpation of the transverse processes of the atlas and the axis and the relation between these two cervical vertebrae.” Also it was found that in the MD group “the atlas was found to be significantly more often tilted to the left and the axis to be significantly more often rotated to the right side than in the control group.” It was interesting that Bjorne et al found that there was not much difference between the MD group and the control group in terms of forward head posture. My view is that the centre of gravity of the skull is determined as being directly over C7, and thus any deviation of the skull forward of this point should be considered as forward head posture and thus relatively abnormal. The fact that they found people in the control group with this posture, would indicate to me that the incidence of CSD is much higher in the normal population, especially since some in the control group also exhibited pain/complaint areas. For example, in Table 1, page 3 of Bjorne et al paper suggests 29% of the control group had pain in the neck/shoulder area, 13% had TMJ pain, and 21% had pain in the vertex area. In the discussion section of the paper it is stated that “it seems reasonable and logical that patients with severe signs and symptoms of CMD also report more pain and complaints in the TMJ/ear area and in the temple regions than do the control subject.” The pain in the vertex area it is reported “may be explained as a referred pain caused by irritation and/or entrapment of the first (C-1) and second (C-2) cervical nerves, greater occipital nerve and vascular structures.” The vertigo, it is explained may be due to proprioceptive feedback from the proprioreceptors in the neck joints, as it is well known that “the vestibular and neck proprioceptive systems interact closely and contribute to postural and eye movement control.” In fact, the upper cervical spine is rich in proprioceptors, whose job it is to provide positional information back to the brain. It seems plausible to me that incorrect positional data is relayed to the brain via these neck proprioreceptors is in fact a major cause of dizziness, and vertigo in people with and without MD. “According ot Bogduk [20] a disturbance of the tonic neck reflex could cause vertigo, as hypertonicity of the neck muscles appears to be a distortion of the normal afferent input to the vestibular nucleus from the neck. Along with the eyes and the labyrinths, the proprioception in the cervical spine is the main influence to the postural system.” This very fact offers an explanation to me as to why correction/adjustment of the atlas by upper cervical chiropractors reverses MD and favourably alters postural distortions. Bjorne et al cite Rubinstein [21] as finding “one-third of her tinnitus patients could manipulate their tinnitus (I assume volume) by movements of the mandible and putting pressure on the jaw.” Certainly I found this to be correct in my own case. Simply yawning, pushing both fists into the sides of my jaw and twisting or pushing up my jaw from the bottom would elicit much higher tinnitus volume, something like 5 times the volume. Could pressure on the lateral pterygoid be affecting the Eustachian tube? So this, according to Bjorne et al “supports an association between jaw muscle tension and tinnitus” and “a study by Lockwood, et al [23] supports our belief in a non-cochlean associated tinnitus.” In conclusion Bjorne et al state “the results of this study show that patients diagnosed with Meniere’s disease have signs and symptoms of CSD that are much more severe than does the general population”, such as neck, shoulder, TMJ, temple and vertex pain; vertigo triggered by shifted posture and head/neck movements; tinnitus changes with mandibular movements; tenderness to palpation of the transverse processes of the atlas and axis; tenderness to palpation of the trapezius and levator scapulae; and limitations in neck mobility or reduced ROM.This paper and others reinforce my view that cervical spine problems, in particular the upper cervical spine are direct contributors to disease and if corrected can initiate the healing process. I suggest a multifaceted treatment approach including, but not limited to ‘specific’ upper cervical chiropractic and TMJ dentistry. See my ‘Total Wellness Approach’ section for my suggested treatment approach.
References	See the paper for a full list of references used by Bjorne et al.2. Kitahara M: Meniere’s disease. Tokyo: Springer, 199020. Bogduk N: Cervical causes of headache and dizziness. In: Grieve GP, ed. Modern manual therapy of the vertebral column. Edinburgh: Churchill Livingstone, 198621. Rubinstein B: Tinnitus and craniomandibular disorders-is there a link [thesis]? Swed Dent J Suppl 1993;95 1-46 23. Lockwood AH, Salvi RJ, Coad ML, Towsley ML, Wack DS, Murphy BW: The functional neuroanatomy of tinnitus. Evidence in limbic system links and neural plasticity. Neurology 1998; 50:114-120
Keywords	Meniere’s Disease, vertigo, tinnitus, hearing loss, atlanto-occipital, atlanto-axial, cervical spine

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