First do no harm

Thursday, March 15, 2007

The room spins wildly around and you become intensely nauseous. Not a ride at your local amusement park, not the residual of an all night party, but instead, you are challenged with vertigo. The symptoms are nasty and incapacitating; the illness may have a variety of causes, from trauma to inner ear issues to strokes to the most common cause, idiopathic, meaning we just don’t know.

Balance is a complicated business. The labyrinth system or the inner ear has a gyroscope mechanism that tells the brain where the body is in relation to the world. To be in tune with your surroundings, the gyroscope needs to work and the brain needs to interpret the signals. The labyrinth can get messed up because of virus infections or because of repeated head movements (like using a computer to enter data or cleaning cupboards above your head) or just because. The cerebellum or the back part of the brain can misinterpret the signals because of a tumor or a stroke, so vertigo is not a symptom to be taken lightly. Fortunately, by history and physical exam, your doctor should be able to distinguish loss of balance due to an inner ear issue from incoordination from a brain problem.,

If it is an inner ear problem, then depending on the reason, the treatment may include medications or physical therapy or both. Vestibular therapy is one of those…I can’t believe this actually happened moments. People unable to move because of the vertigo and vomiting are up and walking in a few minutes after therapy. The downside? This requires a specially trained physical therapist and there aren’t many around…yet.

So why do no harm? In caring for patients, there is great opportunity to have complications. Some are inevitable but others may be systemically preventable.

This week, I presented a poster at the American Academy of Emergency Medicine scientific assembly that discussed a young woman with neck pain who visited her local chiropractor for an adjustment. A couple of days later, she showed up in the ER with intense vertigo. The final diagnosis was cerebellar stroke due to tearing of both vertebral arteries in her neck because of her neck manipulation. The brain has four big arteries that supply it with blood; two carotids in front (right and left) and two vertebral arteries that supply the base of the brain and run in grooves within the vertebral bodies of the neck. This woman had the bone-encased arteries torn stopping the blood supply to parts of her brain that dealt with coordination and balance.

Chiropractic medicine has its place in the care of patients and their research has withstood scrutiny to show how effective it is with low back pain, but neck manipulation is a sore subject that generates great controversy. The Canadian Stroke Consortium and the American Academy of Neurology warn about the dangers of chiropractic neck manipulation. The groups say that neck manipulation is the leading cause of stroke in people younger than 45 and those with stroke are 5 times more likely to have visited with a chiropractor in the previous week. Articles in the Journal of Manipulative and Physiologic Therapeutics, a chiropractic journal, discuss the risk, benefits and the relative safety of neck manipulation.

Appreciate that while vertigo may seem to be an inconvenience, on occasion it can be a big deal.

From the Hippocratic Oath:

I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.

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