Know Your Dizziness
Correct diagnosis is half the cure.
To make the correct diagnosis the clinician will need dizziness specific information from the patients. The aim of the "Know Your Dizziness" section is to provide some basic information to equip patients for their consultation.
How do we achieve balance control?
Balance control is a complex mechanism achieved by interactions between peripheral (sensory) and central (brain) structures.
Peripherally, vision, proprioception and vestibular (Inner ear) systems contribute to balance control. Centrally, structures within the brainstem, cerebellum and several other brain areas are involved in processing the balance signals.
The multi-sensory balance signals help achieve balance control outputs such as spatial orientation, gaze stability and postural stability. The vestibular system is exclusively responsible for sensing static position and dynamic movements of the head.
What is the role of Vestibular System in balance control?
The vestibular system is located within the labyrinth/inner ear along with the hearing apparatus. The vestibular system has a vestibule and 3 semicircular canals.
Both the vestibule and semicircular canals have movement sensing jelly-like structures; however, Otoconia, the calcium carbonate crystals are present only within the vestibule, making the vestibule sensitive to gravity. Endolymph circulates within the vestibular system.
The vestibular nerve carries head position/movement-related signals from the SCC and vestibule to the brainstem and cerebellum. The vestibular system receives its blood supply from the arteries that supply the above brain structures.
Do you know what dizziness & vertigo actually means?
Dizziness is a non-specific term used to describe a range of sensations. It can mean a range of different descriptions. However, the clinicians will categorise the descriptions into one of the following subtypes.
Room-spinning or head-spinning sensation
Faint-like feeling
Unsteadiness
Feeling faint or woozy
To diagnose the underlying condition cause(s) of dizziness other characteristics are more helpful than the type of dizziness. Please pay attention to the following:
What causes dizziness/vertigo?
Click a region on the diagram
Dizziness & Anxiety
A patient can have both dizziness and anxiety.
While anxiety can cause dizziness, dizziness-induced anxiety is very common too. If the root cause of dizziness is anxiety then the anxiety needs to be tackled by medical and psychological therapy.
If the anxiety was induced by dizziness, then correct diagnosis of the cause of the dizziness and appropriate treatment (VRT) of it along with patient education can help ease the anxiety. However, if the anxiety is severe, or not improving with VRT alone then the patient would require medical and psychological therapy.
Labyrinthitis
Inflammation of the labyrinth causes vertigo, unsteadiness and LOSS of HEARING.
Both viral and bacterial infections cause labyrinthitis. Unless it is a bacterial infection the labyrinthitis is unlikely to recur.
Labyrinthitis causes acute vestibular loss (vertigo & unsteadiness). Lack of appropriate treatment leads to chronic vestibular hypofunction and other secondary complications.
While medication therapy is helpful for short-term symptomatic relief at the acute stage, long-term use of it can hinder the natural recovery and certain medications can even cause untoward side effects such as Parkinsonism.
Meniere's Disease
Meniere's disease comes in attacks of vertigo lasting for minutes to hours along with hearing loss. In the early stages of the disease, hearing loss is fluctuating, meaning that the hearing will recover after each acute attack, however, it may become permanent as the disease progresses. In some patients, it can affect both sides.
As for the control of the acute attacks, medication therapy and food and lifestyle changes play a significant role.
Vestibular physiotherapy is not helpful during acute attacks, however, it can be very helpful between the attacks to improve balance and reduce motion hypersensitivity and other secondary issues.
Visual Dependency/Vertigo
Certain visual conditions such as walking in the dark, busy supermarkets, watching fast-moving scenes on television or cinema and lack of vision (standing with eyes closed) causes dizziness and unsteadiness. This happens because of the visual dependency for balance control.
Customised balance exercises help improve the visual dependency and visual vertigo.
Vestibular Hypofunction
Lack of/reduced vestibular signals will lead to vestibular hypofunction.
Labyrinthitis, vestibular neuritis, concussion of the vestibular systems and ototoxicity can cause acute vestibular hypofunction. Untreated acute vestibular problems lead to chronic vestibular hypofunction. Additionally, in elderly people age-related deterioration of the inner ear system also lead to vestibular hypofunction.
Vestibular physiotherapy helps diagnose and treat both acute and chronic vestibular hypofunction.
BPPV — Benign Paroxysmal Positional Vertigo
BPPV is caused by free-floating crystals within the semi-circular canal.
The free-floating crystals can be present in any of the 3 semicircular canals. Therefore, all three canals need to be tested with respective positional tests.
BPPV is treated with positional manoeuvres. Epley will only work in cases of posterior canal BPPV and it will not work for the other canals. Medications, Brandt-Daroff exercises and Cooksey-Cawthorne exercises do not help cure BPPV.
Multi-sensory Dizziness
Balance control is a multi-sensory process involving vision, muscles and joints, inner ear balance system and brain. Involvement of all three peripheral balance systems result in multi-sensory dizziness. It is common in elderly people and it increases the risk of falling in this age group significantly.
A comprehensive balance assessment including falls risk assessment and targeted balance exercises including education on falls prevention help improve balance and reduce the risk of falls.
Persistent Postural-Perceptual Dizziness (PPPD)
PPPD is a functional vestibular condition caused by both vestibular and non-vestibular causes.
In PPPD the vestibular symptoms are persistent on most days and triggered/aggravated by certain postures, head and body movements and visual environments.
Subjective diagnostic criteria is used for the diagnosis of PPPD. It is treated with customised VRT and may require medication therapy and psychological counselling.
Cervicogenic Dizziness
Neck's proprioceptive input is an integral part of the balance control mechanism. Therefore, issues affecting the neck such as arthritis, whiplash and neck pain can cause dizziness and unsteadiness.
Similarly, patients with dizziness are more likely to develop neck pain due to the dizziness-imposed neck stiffness.
Cervicogenic dizziness benefits from customised physiotherapy.
Vestibular Migraine (VM)
Vestibular migraine can cause vestibular symptoms such as vertigo, dizziness and unsteadiness. VM can happen without headaches too.
VM symptoms type and duration can mimic BPPV, VN, TIA and Meniere's disease etc. This chameleon nature of the VM can confuse both the clinicians and patients.
VM is diagnosed based on A1.6.6 Vestibular migraine — ICHD-3 and elimination of other possible causes.
Treatment of VM consists of food and lifestyle modification, medication therapy and customised VRT.
Motion Hypersensitivity (MHS)
MHS is a functional vestibular disorder in which certain head and body movements and positional changes induce dizziness. This can mimic BPPV.
Habituation exercises help reduce motion hypersensitivity.
Vestibular Neuritis (VN)
Inflammation of the vestibular nerve causes vertigo, unsteadiness. But it does NOT affect the HEARING.
However, erroneously patients were given a diagnosis of labyrinthitis when hearing was not affected with the acute vertigo attack.
Viral infections cause vestibular neuritis, therefore, it's unlikely that it will recur.
Lack of appropriate treatment leads to chronic vestibular hypofunction. While medication therapy is helpful for short-term symptomatic relief at the acute stage, long-term use of it can hinder the natural recovery and certain medications can even cause untoward side effects such as Parkinsonism.
Correct diagnosis and early start of vestibular physiotherapy significantly improves the outcome.
Mal de debarquement syndrome (MdDS)
MdDS sufferers experience sensations of rocking, bobbing or swaying. These symptoms are more pronounced when standing still compared to walking.
MdDS occurs commonly after a cruise, however, sometimes MdDS-like symptoms can occur without being on a cruise (Pseudo MdDS).
Readaptation of the VRT and sensory reweighing training helps reduce the MdDS symptoms. In cases of pseudo MdDS, diagnosing and addressing the underlying cause of it, in addition to the readaptation of the VOR and sensory reweighing training will help improve the symptoms.
Stroke — Central Vestibular Dizziness
Stroke affecting the balance controlling part of the brain (midbrain & cerebellum etc) causes vestibular symptoms such as vertigo, dizziness and unsteadiness.
In addition to regular physiotherapy, these patients will require vestibular and balance specific exercises to address the vestibular symptoms.
Head Injury/Concussion
Head injury/Concussion frequently causes dizziness, vertigo and unsteadiness due to the impact on the vestibular systems and/or balance controlling part of the brain such as midbrain and cerebellum etc.
Dizziness in patients with head injury/concussion often erroneously seen as symptom of the post-traumatic stress. As a result, underlying real issues often left unrecognised and untreated.
Vestibular physiotherapy is beneficial to reduce dizziness and improve balance in patients with concussion/head injury.
Acoustic Neuroma
A slow-growing tumour on the vestibulocochlear nerve (balance & hearing) causes dizziness, unsteadiness and gradual worsening of hearing on the affected side along with other signs.
Though this is rare, in patients with above presentation acoustic neuroma needs to be ruled out. Your doctor might refer you to a neurologist/ENT to get this checked.
Post-operative vestibular and balance physiotherapy is helpful in patients who underwent surgical treatment.
Multiple Sclerosis (MS)
Dizziness is common in patients with multiple sclerosis. While there could be many reasons, peripheral and central vestibular causes need to be evaluated and addressed appropriately.
Vestibular physiotherapy can be helpful to address vestibular issues in MS.
Vertigo
Vertigo = Room/head spinning sensation
It is not a condition, it is a symptom of an underlying condition(s).
Therefore, treatment of vertigo should begin with the correct diagnosis of the underlying cause of it.
Unfortunately, vast majority of the patients with vertigo are being treated symptomatically without diagnosing the underlying cause of it. As a result, patients continue to suffer from it for months to years without a relief.
"Not all vertigo is BPPV"
Apart from BPPV, vertigo is present in a lot of other vestibular conditions. To treat vertigo successfully, the underlying cause needs to be diagnosed correctly, rather than assuming it is BPPV and treating it with Epley.
Dizziness/vertigo is not a condition — it is merely a symptom of an underlying condition. The causes can range from trivial to life-threatening. Fortunately, the most commonly occurring dizziness is due to benign conditions such as BPPV, Vestibular migraine, age-related multi-sensory balance issues and PPPD.
The vestibular-specific examination is helpful to diagnose most common vestibular disorders. Except in rare cases, investigations such as MRI, CT scan and blood tests are not helpful to diagnose dizziness.
What is Vestibular Rehabilitation (VRT)?
Vestibular rehabilitation (VRT) is a specialised form of therapy intended to alleviate both primary and secondary problems due to vestibular disorders. It is an exercise-based program primarily designed to reduce vertigo and dizziness, reduce gaze instability, and/or reduce imbalance and fall risk as well as address any secondary impairments.
How vestibular disorders are treated?
When it comes to the treatment of vestibular disorders "One-Size-Fits-All" will not work. Treatment needs to be customised and patient-centred.
Vestibular Facts
1 in 3 people aged 40 years and 85% of people aged 80 years and above suffer from vestibular balance problems.
Over 80% of people with vestibular disorders experience impacts in their daily activities.
Of people change their job due to dizziness. 21% give up work entirely, and 50% have reduced efficiency at work.
Experience disruption in social life, 35% have family difficulties, 50% have difficulties with travel.
Medication Facts
Routine use of vestibular suppressants are not recommended for BPPV treatment as they could obscure clinical presentation.
Long-term medication use can:
- Interfere with central compensation
- Cause cognitive dysfunction
- Increase fall risk
- Cause drug-induced Parkinsonism
Vestibular Physiotherapy Benefits
- Effectively diagnoses and treats all types of BPPV
- Safe and effective for vestibular hypofunction
- Reduces dizziness and improves balance
- Reduces fall risk
- Improves balance confidence and daily activities