As vertigo and symptoms of dizziness are one of the top 5 reasons individuals seek medical attention, I feel it is necessary to understand both the symptoms themselves, and what is likely causing them.  These frightening and often debilitating symptoms have many potential causes, and proper assessment and diagnosis is essential to treating them effectively.

First we must understand the symptoms.  Vertigo is derived from the Latin “vertere”, meaning to turn.  Vertigo is always associated with a sensation of turning or spinning, whether it is the individual spinning, or the environment spinning around the individual.  Most cases involve the environment spinning around the individual, which is most often a less complicated presentation.

Dizziness is often described as “lightheadedness” or feeling as if one is going to faint.  Spinning is typically not associated with dizziness.

Disequilibrium is a loss or alteration in our sense of balance, often associated with feelings of being “on a boat” or the effects of alcohol on the way we walk and perceive ourselves relative to the environment around us (“drunken gait”).

Nausea and/or vomiting often accompany vertigo and may, although less often, be associated with dizziness and disequilibrium.  Dizziness and disequilibrium typically do not lead to vertigo, but untreated vertigo will often lead to complications with these two symptoms due to compensatory changes within the nervous system.

There are many possible causes of vertigo, but, by far, the leading cause is related to debris (otoconia) made up of calcium carbonate crystals that dislodge from their proper place within the inner ear canal system.  This condition, called Benign Paroxysmal Positional Vertigo (BPPV), is due to the disruption of signals transmitted to the brain regarding angular acceleration of the head from this debris in the affected ear canal.  Fortunately this condition is treated with great success via head positioning maneuvers designed to relocate the debris to its proper location, followed by rehabilitation for the inner ear vestibular (balance) organs.  Aging and head trauma are the two main predisposing factors for BPPV.  The one major drawback is that this condition is often not assessed appropriately, therefore leading to an incorrect diagnosis.

Other causes of vertigo include Vestibular Neuritis/Neuronitis, which, as its name implies, involves inflammation of the inner ear.  Although treated with anti-inflammatory agents, symptoms often persist and require rehabilitation of inner ear vestibular organs.  Meniere’s Disease, which consists of a triad of symptoms including vertigo, tinnitus (ringing in the ears) and progressive hearing loss, is caused by an increase in a certain type of fluid within the inner ear causing pressure on balance and hearing centers.  Considered a more ominous and poorly understood condition, certain types of therapeutic interventions can be effective, especially with regard to the vertigo component.   Perilymph Fistula is a defect in the membrane, or window, between the middle and inner ear causing pressure changes affecting the inner ear.  A certain class of antibiotic medications (aminoglycosides) can cause damage to the eighth cranial nerve leading to vertigo and hearing loss.

As with vertigo there are many causes of dizziness, a list too exhaustive to explore here, but many are related to medication side effects (it is one of, if not the most common medication side effects across all classes of medications) and changes in heart rate and blood pressure (Postural Hypotension and Vasovagal Syncope).  Anxiety disorders and panic attacks may lead to dizziness as well.

Disequilibrium is often related to alteration or disturbance in central (brain) feedback from any of the major systems related to balance including visual, muscle and joint (proprioceptive), and inner ear vestibular systems.  The number of metabolic, physical and functional conditions that may affect these systems is quite lengthy as you could imagine!  Alcohol, recreational and therapeutic drugs, and environmental exposures, among many other triggering agents, can play a large role in disruption of equilibrium.  As noted, untreated vertigo will likely lead to symptoms of both dizziness and disequilibrium.

Treatment for all disorders is wide ranging and the effectiveness of any given treatment is dependant upon the accurate diagnosis of the condition creating the symptoms.  The bottom line is that all conditions affecting balance will likely benefit from active rehabilitation of the involved systems once the causative factor has been established.  Although to the individual experiencing these symptoms it appears that the prognosis is hopeless, long term outcomes are favorable for the vast majority of conditions outlined!  Diagnostic and treatment interventions will be discussed in greater detail in future articles.

Dr. Michael S. Trayford is a Board Certified Chiropractic Neurologist who has undergone extensive training in diagnosis and management of vestibular/balance disorders and fall prevention therapies.

While a thorough neurological history and examination with a qualified professional should be performed for any suspected head injury, particular emphasis should be placed on the cranial nerves – the nerves that exit your brain and brainstem.  Of these cranial nerves, the most telling findings will likely come from the ones involved in vision and eye movement (cranial nerves 2, 3, 4 and 6).  It is also critical to assess higher brain centers that control various eye reflexes, which will be discussed later in this article, during the eye examination as well.

There are many types and causes of head injury, but, by far, the most common are concussions related to motor vehicle accidents and contact sports.  Concussion comes from the Latin ‘Concutere’, which means to shake violently.  Most experts would agree that these are the least serious type of brain injury; yet left untreated many can suffer devastating and debilitating consequences such as vertigo/dizziness, balance problems, cognitive dysfunction, emotional disorders, headaches, and many others.

Given concussions are ascribed this ‘low severity’ status, timely evaluation and treatment is often poor or non-existent at best.  Patients are often treated with a ‘sit-and-wait’ approach; meaning it is only after signs and symptoms have manifested and worsened that people often seek care of their own accord.  This is entirely unacceptable as early intervention is critical with concussion, as is the case with most disorders of humankind, and it may significantly decrease the likelihood of more serious consequences.  The longer one’s brain is adapting to negative changes incurred as a result of a head injury (referred to as maladaptive plasticity), the longer it will take to rehabilitate their way out of them!

Shifting our focus back to the eyes (pun intended); most individuals that have suffered a concussion will complain of some type of symptom related to eye function (e.g. blurry vision, light sensitivity-photophobia, eye fatigue, double vision-diplopia, reading difficulties, etc.).  I cannot honestly recall a single case of concussion presenting to my office in the recent years that did not have some type of visual or oculomotor (eye movement) consequence.

We have all seen at some point on TV or the ‘Big Screen’ a doctor shining a light in someone’s eyes to look for lack of pupil constriction as the one and only diagnostic factor for concussion.  Well I’m here to tell you that they need to be looking at a great deal more than that!  Some basic tests to look for when you or a loved one is being examined for suspected concussion are as follows:

1)      Observation for eye malpostion

2)      Direct and indirect pupil response to light (as noted above)

3)      Cardinal fields of gaze (eye movements in all directions)

4)      Eye convergence (crossing of the eyes – as your mother told you to never do!)

5)      Ophthalmoscopic examination (looking inside the eyes)

6)      Visual acuity/Snellen chart (how well you see)

7)      Eye cover/uncover testing (more sensitive test for eye deviation)

8)      Eye dominance and/or suppression testing

While not an exhaustive list, these tests can be done in a very short period of time (5 minutes or less) with very little equipment and can reveal a great deal about the integrity of these cranial nerves, as well as the higher brain centers that regulate these functions.

That said, there are a host of other very sensitive tests that can offer clinicians incredibly valuable insight into the workings of the ocular (eye) system and its connections with most parts of the brain.

1)      Vestibulo-ocular reflex (VOR) testing – often performed with the patient focusing on an object while the examiner moves the head, or while the patient is rotated in a chair

2)      Testing for eye saccades (fast movements between targets) – movements are typically over or under compensated with concussion

3)      Cortical blind spot mapping – mapping of the visual defect created by the optic nerve attaching into your retina where there are no receptors for light (rods/cones)

4)      Testing for optokinetic nystagmus (OKN) – reflexive eye movement caused by tracking of movement within a visual field (i.e. similar to looking out a car’s side window while moving)

5)      Electronystagmography (ENG)– advanced electrical testing of various ocular capabilities

Once again, this is by no means an exhaustive list of assessment tools available to the practitioner for evaluation of the eyes and associated brain systems after a head injury, and evaluation options will vary depending on the type of practitioner utilized for assessment (e.g. DC, DO, MD, PT, PhD, etc).

In my humble opinion, given their astute focus on ‘functional’ abnormalities of the nervous system, functional neurologists such as Chiropractic Neurologists and Neuropsychologists are best equipped to deal with these types of conditions; meaning those injuries where there is no observable ‘structural’ damage to the brain.  It is no secret that our modern health care system fails to acknowledge and treat these ‘functional’ brain injuries effectively and the long term ramifications of this ‘sit-and-wait’ behavior can be absolutely devastating.

In closing, while I agree there is a greater awareness of brain injury given the publicity provided to it primarily from the great men and women that have been injured serving our country in the past decade or so; I still feel the attention and treatment given to those with ‘milder’ brain injuries like concussion is poor at best within our current system.  And this opinion is validated and reinforced daily in my clinic when I see the changes in folks and their families that have been advised to ‘sit-and-wait’.  While many sports programs at all levels are implementing strategies such as sideline visual tests like the King-Devick test that are remarkable for evaluating concussion within minutes of the injury, the passive after-care approaches have not changed a whole lot.  I am here, along with my colleagues, to ensure that those suffering concussions do not ‘sit-and-wait’, and that they get the evaluation and intervention necessary to return them to their pre-injury (or better) status.  Please help us in this mission and pass this on to everyone you know as no one is immune to the possibility of head injury!

~Please check back soon for a follow-up article focused on potential treatment interventions for concussion and TBI~

What You Don’t Know CAN Hurt You

In a much anticipated follow-up to my recent post “Can Type II Diabetes Double Your Risk of Dementia?”, I felt it was important to arm you with the basic knowledge necessary to combat the growing threat of blood sugar handling issues, namely Adult Onset (Type II) Diabetes and pre-diabetes.  The staggering statistics revolving around these 21^st century societal conditions were outlined in the aforementioned article, as was the substantial risk of developing dementia as a result of sustained elevations in blood sugar; dementia being only one of numerous ramifications related to challenges with blood sugar handling!

The focus of this post will be “Blood Sugar and Your Brain”, with other factors such as exercise and stress management, among others, to be addressed in future articles.  Addressing fuel delivery, sugar being one of the two primary fuels for your body and brain (the other being oxygen), is the most basic, and very likely the most important, step in maintaining and elevating your current level of health and diminishing your risk of  health problems related to poor blood sugar handling.

First, a bit of understanding is necessary.  The brain has been termed the “Greedy Master” due to the exorbitant amount of fuel it consumes relative to its size.  Being only a mere 2% (yes two percent) of our body weight, your brain cells consume nearly 2 times more energy/fuel than other body cells – one half of this being used for nerve conduction!  To boot, neurons are ALWAYS metabolically active (always using fuel) and they cannot store energy (unlike muscle and other types of cells).  Given this insight, you can easily see how the brain requires an adequate, appropriate, and consistent method of fuel delivery.  Any disruption in this delivery, either short or long term, can have devastating consequences in our brains and bodies!

At this point in time many view ‘sugar’ as the human race’s quintessential evil nemesis, based largely on misinformation from the food and diet industries over the past 50 years or so (more in the past 10-15 years).  I’m here to tell you that sugar is not bad, it is the misunderstanding or general ignorance about the types of sugar available to us that is dangerous!  The right types of sugar, in fact, are necessary for our survival and for our level of human performance, or lack thereof.

Complex vs. Simple  carbohydrates (sugars).  In a nut shell – Complex carbohydrates  wear a ‘jacket’ of fiber that slows the breakdown of the carbohydrate and subsequent release of sugar into your blood stream (think ‘metered in’).  These are found in natural food sources – think of fruits, vegetables, grains, and beans with edible skins or ‘jackets’.  These are the best for your brain and should be your primary source of sugar intake.  In sharp contrast, Simple carbohydrates have little to no fiber and require less breakdown; therefore their sugars enter the bloodstream much more rapidly (think ‘explode in’).  These are found primarily in processed or refined food sources and many of these sugars will never reach the blood-brain barrier; which supports one of the likely theories of what causes dementia (i.e. inadequate brain fuel).  The takeaway here is the more consistent and the longer the delivery of fuel, the more efficiently your brain and body will work.  So, what kind of carbs are you eating???

Glycemic Index (GI) is an extremely important concept/application for us to comprehend, even at the most basic of levels.  Simply stated – GI is a measure of the effects of carbohydrates on blood sugar levels.  Given your new understanding of carbohydrates based the simplified explanation of Complex vs. Simple carbs provided above, you will now learn that rapid breakdown of carbohydrates = high glycemic index and slow breakdown of carbohydrates = low glycemic index.  Or, in other words (in most cases), high GI = bad, low GI = good.  Many charts of common food indices can be found online – click here for one example from Harvard Health Publications.

As we do not have the time here to discuss the individual mechanisms of disease as related to poor blood sugar handling, what you need to understand as related to the topic at hand is that elevated, uncontrolled blood sugar levels lead to damage to small blood vessels within the brain and body.  This damage leads to impaired fuel delivery and is at the root of many neurological disorders, including dementia.  Processed sugars, which you just learned very often do not reach the blood brain barrier, cause little or no insulin response and are likely responsible for the faulty, ineffective Beta cell insulin responses of the pancreas found in those with Type II Diabetes.  Further, there is little suppression of appetite with Simple sugars (unlike the suppression found with Complex carbohydrates) that leads to chronic cravings for this type of ‘fast’ energy (an addiction of sorts).

Label Reading – it is imperative to have a basic understanding of what the food labels on your foods say about what is contained within that package.  Even foods bought in some of the more ‘health conscious’ supermarkets can contribute to your risk of developing blood sugar problems.  Here are the keys when trying to understand the sugars in your food:

1)      We should concern ourselves primarily with quantities of Sugar and Fiber only

2)      Sugar relates to ADDED sugar

3)      Think lower Sugar, higher Fiber

4)      The greater the difference between Total Carbohydrate and Sugar, the better the food (i.e. less added sugar)

5)      Other Carbohydrates generally refers to complex starches contained in the food that don’t have much of an  impact on GI

6)      Sugar goes by many names – begin to educate yourself on the various ‘aliases’ (Click here for examples from Mayo)

As many wise folks in generations prior have told us – “You are what you eat”.  If you continue to eat highly volatile, quick energy foods (i.e. simple sugars) on a regular basis, your body and brain will ‘burn out’ long before its ‘expiration date’.  On the other hand, if you move towards whole foods (i.e. complex carbohydrates) that ‘meter in’ and ration your energy, you can bank on the fact that you have done a great deal in ensuring a life with a significantly decreased risk of serious brain and body health complications!

For years we have held the belief that challenges with blood sugar handling, especially the hyperglycemic variety, are at the root of a host of disorders of humankind; in our practice the primary interest being on neurodegenerative disorders.  A recently published long-term study supports this belief, and offers hope in battling one of the most devastating of all human conditions – dementia.

According to a Japanese Study “Glucose tolerance status and risk of dementia in the community – The Hisayama Study” printed in the September 2011 issue of the journal Neurology, there is clear evidence to support the fact that individuals with adult onset diabetes (Type II) are at a significantly higher risk for developing various types of dementia (including Alzheimer’s type dementia).  Some of the evidence presented in this study points to double the risk of developing dementia if you are a Type II diabetic vs. being a non-diabetic.  This risk was also shown to be significantly increased in those with ‘pre-diabetes’, or borderline high blood sugar levels.  Estimates from the American Diabetes Association put 79 million Americans in the ‘pre-diabetic’ category, over 3 times greater than the number of Americans with any type of diabetes (just about 1/4 of our total population!!!).

What is the reason for developing dementia as a result of having diabetes?  Although this study was focused primarily on the rates of development of dementia in a population and not the actual mechanisms of the disease itself (there are several types of dementia), it is also important to consider concurrently with this study the role elevated blood sugar plays in our declining health that has been widely studied in various health science disciplines.  From small blood vessel damage and the brain’s impaired response to insulin, to oxidative stress, inflammation and fat deposition; excess blood sugar ultimately leads to impaired fuel delivery to what is considered by most to be ‘pound for pound’ the most metabolically active organ in our body (the brain being roughly 2% of our body weight consumes 10-20% of our energy stores!).  Impaired fuel delivery to our brain leads to dysfunction with nerve transmission, neuronal growth and connections, effectiveness of neurotransmitters, and, ultimately, cell death.

It is more important than ever for us to gain control over our blood sugar levels and decrease not only our risk for developing dementia, but for so many other conditions of humankind.  We will explore dietary and lifestyle changes that will have a dramatic impact on your blood sugar handling shortly in upcoming posts, so stay tuned for more life-changing information!

As a final thought – Imagine the impact we could have on the over $350 Billion burden placed on our health care (or sick care depending on how you look at it) system by diabetes and Alzheimer’s disease alone!

Released in January of 2008, the book Spark was a catalyst for massive change in my own personal life. Being a perpetual student of neurology, and more specifically neuroplasticity, I am always on the lookout for new resources to share with my patients to help them on their quest for optimal health. Dr. John Ratey does a superb job in this book outlining the physical changes that occur in our brains as a result of the various types of physical activity/exercise we perform; and for those that don’t exercise, it will give you incredible motivation to start the journey!

Many of us exercise because we feel we “have to”, or to burn calories, lose weight, build muscle and look better. While these are good reasons, they typically do not sustain the motivation we need for lifelong health. Dr. Ratey helps us to understand the countless chemical compounds that are produced as a result of various types of exercise (such as insulin like growth factor – IGF1, vascular endothelial growth factor – VEGF, brain derived neurotrophic factor – BDNF), and what these compounds do to improve our ability to handle blood sugar, repair blood vessels and establish connections within our nervous system.

It has been shown that our thoughts and emotions are an internalization of our body movements.  The way we move our bodies, and understanding the impact this has on our brains, is critical for battling many behavioral, psychological, biochemical and physical conditions. Dr. Ratey outlines 7 specific conditions including anxiety, depression, and ADHD among others; which can benefit tremendously with appropriate and adequate physical activity.

There is an abundance of evidence supporting neurogenesis (new brain cell growth) as a result of physical activity, and this is explored within the pages of this book as well.

When you are done with this book you will feel that losing weight and looking better is merely a pleasant side effect of exercise, and not necessarily the most important effect. I can speak from personal experience that this book will significantly change the way you view exercise as it has added a tremendous amount of new life to my quest for optimal health – and it has been nice to lose a few pounds and look better in the process!!