Dizziness, vertigo and balance problems affect many of us; as many as 50% of all adults may experience some type of these problems in their lifetime! It is important to distinguish between dizziness, vertigo and balance issues because they are not the same and there are many different causes for these problems. It is important to get a thorough physical examination from your physiotherapist to determine what exactly you are suffering from, and more importantly, create a plan to treat it!
So about dizziness. What causes this? There are many reasons for this including concussion, cardiovascular problems, mechanical neck issues, neurological or visual dysfunction as well as vestibular disorders. The most frequently seen causes of dizziness in a physiotherapist’s office are mechanical neck pain from injury, posture or trauma. This type of dizziness is easily treatable with hands-on, manual physiotherapy. A second common cause of dizziness is vestibular dysfunction.
Dizziness from vestibular disorders is called vertigo. This is different than the dizziness which accompanies cervical spine dysfunction; vertigo is often described as a rotational sensation where either the individual or the surrounding area is spinning, as opposed to a feeling of unbalance of disequilibrium.
The vestibular system, which contributes to balance and to the sense of spatial orientation in most mammals, is the sensory system that provides us with information about movement and sense of balance. Together with the cochlea, a part of the auditory system, it constitutes the labyrinth of the inner ear and is situated in the vestibulum or cavity of the inner ear.
How the heck do I injure my vestibular system? It can be caused by head trauma, ear infections, high dosage of certain drugs, vestibular degeneration, barotrauma (tissue damage due to a difference in pressure), or vascular insufficiency. Some of the signs of vestibular disorders are nystagmus (involuntary eye movement), vertigo, nausea, vomiting, dizziness and imbalance.
Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of a vestibular disorder and affects 20-30 percent of patients assessed for vertigo. It can occur at any age but is more prevalent among older adults. In 35% of cases, BPPV can occur without any instigator; 15% follow head trauma and 15% after an inner ear infection (1). Those with BPPV may report vertigo with possible nausea when bending forward, turning over in bed, looking up and laying down. This acute vertigo will last less than a minute with each episode; however, the sense of unbalance can be ongoing.
Knowing the anatomy of the inner ear makes it a bit easier to understand the mechanisms behind BPPV. There are three semi-circular canals that are at right angles to each other in the ear and these organs sense rotational movements, such as nodding your head in an up and down motion or back and forth. Attaching to the canals are two structures called otoliths which sense linear movements. There is also fluid that bathes these structures and specialized hair cells that act as sensors for movement. Attached to the projections of the hair cells are otoconia or calcium carbonate crystals.
The semicircular canals sense movement as a body or head rotation causes the fluid to move in the opposite direction. With a normal vestibular system, this information is then transmitted to your brain or central nervous system (CNS) and your body automatically adapts itself to the motion.
It is hypothesized that the most common cause of BPPV occurs when these little crystals attached to the hair cells, break loose and become free-floating in the semicircular canals. When the head moves the crystals will move to the most dependent part of the canal. This causes movement of the fluid which then pulls on the sensory organs and gives faulty information to the CNS, resulting in vertigo and nystagmus. When the crystals stop moving, the organs return to normal and the symptoms of vertigo and nystagmus cease.
There are specific tests to determine if in fact what you are feeling is truly a vestibular dysfunction. A test called the Epley Manoeuver is performed which aims to reproduce the sensation of vertigo. A positive test is the reproduction of vertigo and nystagmus. Physiotherapists trained in the treatment of this disorder have a specific technique to reposition the crystals called the Dix-Hallpike Maneuver. This involves moving the individual’s head in moderate extension while rotating the head in such a way that moves the crystals out of the semicircular canals and back into the sensory organs. There is approximately a 40 percent reoccurrence rate (1). One study followed 50 patients with BPPV for a mean of 52 months and it was found that there was a reoccurrence rate of 18 percent by 1 year and 30% by 3 years (1).
Vestibular neuritis is the second most common cause of vertigo (1). This is due to a viral infection of the vestibular nerve or the fluid in the labyrinth. The presentation of this is intense vertigo, nausea, nystagmus, and a sense of unbalance which lasts for days until the symptoms subside. Treatment is initially vestibular suppressants and rest. When the symptoms subside, physiotherapist-prescribed vestibular adaptation exercises play an important role. Vestibular adaptation can occur with periods of stimulation for as short as 1-2 minutes. Initially, increased symptoms may be experienced while doing these exercises however they should not last more than 20-30 minutes following these exercises (1).
The assessment and treatment of the “dizzy” patient are becoming much more prevalent among physiotherapists. If you are experiencing ongoing dizziness or vertigo that sounds much like the descriptions above… check in with your physiotherapist. We can help!
Reference: Tonks B, Thompson E. Vestibular Rehabilitation. A Practical Approach.
