By: Gita Mikal, Registered Physiotherapist certified in Vestibular Rehabilitation
Dizziness has many causes. A typical vestibular patient has a history of an acute, sudden dizziness attack which may or may not be accompanied by vomiting or nausea. Some patients experience a sudden unsteadiness and feel lightheaded. In many cases, dizziness and memory problems are the result of an inner-ear disorder, possibly caused by a virus after a bad cold. Difficulty concentrating, memory loss and fatigue develop because the brain is working very hard to keep the body upright, this compromises other brain functions. These symptoms naturally disappear along with the dizziness.
In a good percentage, this dizzy period passes with no recurrence, but many people begin to experience mild to moderate difficulties with daily living, work or sports activities. Gradually it is increasingly hard to concentrate in meetings, watch TV, read a book, go to theater, read street signs when walking, walk on an uneven surface or in a dark room, take the escalator, be in busy environments, etc…
Causes of Dizziness
Nearly one-third of the population reports episodes of dizziness at some point in their lives. 15-20 percent of people reporting dizziness and balance impairment may be experiencing symptoms due to a range of systematic, neurological or neuromuscular conditions such as:
- Cervicogenic Dizziness which is a dizziness originating from neck muscles or arthritis
- Vascular insufficiency causing constraints on blood supply to brain
- Diabetes causing brain blood supply insufficiency
- Toxicity with high doses of certain antibiotics such as Gentamicin
- Brain tumours
- Central Nervous system infections such as Meningitis, brain abscess, encephalitis, Lyme disease
- Multiple Sclerosis(MS)
- Psychological conditions
The remaining 85- 80% suffer from inner-ear disorders, which can be caused by whiplash, blows to the head, viral infections, high doses of certain antibiotics, strokes or degeneration of the inner ear’s balance function, also known as the vestibular system, which often deteriorates with age.
Common conditions causing vestibular dysfunction causing dizziness and vertigo are:
- Benign Paroxysmal Positional Vertigo (BPPV) commonly known as Vertigo
- Inner ear infections such as viral cold infections or Herpes Zoster Oticus
- Vestibular Neuritis
- Vestibular Schwannoma/ Acoustic Neuroma
- Meniere’s Disease
Inner-ear problems cause diverse symptoms as vertigo, nausea and blurred vision, therefore many who suffer from the disorders spend years going from doctor to doctor, only to have their symptoms misdiagnosed as sinus, eye, neurological or psychological problems.
Balance & Equilibrium System
Balance is a complex function that requires accurate information from several sensory modalities including:
Vestibular system: provides information telling the brain where the head is in the space, in what direction it is moving and if it is changing speed of movement. This system provides two-third of the information brain needs to maintain balance
Visual system: Provides brain with information about the word outside, peripheral vision provides information about motion
Somatosensory system: Skin receptors and muscle receptors in the ankle and lower leg provide information from tactile contact with the surface. Muscle proprioceptors in the neck also contribute information about head position
Central Nervous System (Spinal cord and brain): Integrates sensory input and orders muscles to generate a controlled response. To be perfectly balanced, brain constantly receives signals from the eyes, muscles and joints and from the inner ear’s balance organs.
How Vestibular dysfunction causes vertigo, dizziness and imbalance
The balance organs located in inner ear contain Otolith organs (Utricle & Saccule) and semicircular canals filled with moving fluid and small calcium particles. Head movements move the fluid through the canals and Otolith organs, stimulating the nerve endings and sending messages to the brain about the position of the head and the body.
When the inner ear sends the brain incorrect information, or conflicting signals, the person feels dizzy. Naturally, the patient limits movement so as to minimize the rocking or spinning sensations.
What is BPPV?
Not every dizzy or unsteadiness sensation is vertigo. Vertigo is a particular form of dizziness or giddiness. Rather than just feeling faint or light headed, it is an illusion of movement. The sufferer feels as though they, or their surroundings, are turning, spinning, falling, or some other form of movement when in fact they are not. Like sea-sickness, vertigo is often accompanied by nausea and vomiting.
One of the most common causes for vertigo is BBPV (Benign Paroxysmal Positional Vertigo) which is cause by displacement of small calcium particles in inner ear balance organ. Commonly caused by a blow to head, whiplash or a fall, the particles move from Utricle, where they belong, to semicircular canals. These free floating crystals cause irritation in inner ear and sends faulty messages to the brain. Sometimes these particles settle by themselves which resolve the symptoms and many times they get stuck in the canals which cause ongoing dizziness. Acute Vertigo attack can last from minutes to a few days depending what is causing it.
BPPV in a nutshell
- Benign Paroxysmal Positional Vertigo (BPPV) is the number one cause of vertigo. It occurs with change in head or body position, lasting only seconds
- This condition occurs because of changes in the balance portion of the inner ear. Calcium carbonate crystals, which the ear uses as a gravity sensor, move from the utricle into one or more of the balance canals
- Although it may occur at any age, by age 70, fifty percent of all individuals will experience BPPV
- The most common ear conditions that cause BPPV are vestibular neuritis or labyrinthitis. There is no pain, such as with an earache, but you may have initially experienced sudden vertigo and nausea lasting hours
- Common medical conditions such as cardiovascular disease, diabetes, migraine, and TIAs (small vessel ischemia in the brain) may also cause BPPV. Mild head trauma may also cause BPPV
- The most popular treatment for BPPV, is a simple and painless repositioning manoeuvre selected based on your assessment findings. The treatment returns the otolith debris to its originating larger space within the inner ear (utricle). Now, the body can absorb the calcium carbonate crystals within a few days
- The repositioning procedure is not a permanent cure, but a treatment. The condition may recur, and often times it does. It may recur anytime from a few months to years, or perhaps, never. Other medical conditions or prescription medication may promote the recurrence, if they affect the body’s processing of calcium
How does a physiotherapist treat BPPV?
A trained physiotherapist collects detailed information about the condition and medical history, completes a series of clinical tests including observing your eye movements to determine the cause of dizziness.
In acute vertigo caused by displaced particles, a vestibular physiotherapist employs appropriate repositioning manoeuvres to dislodge the particles from the canal and send them back to where they belong which almost immediately resolves symptoms. In many cases, this is enough treatment.
Vertigo and disequilibrium can be very frightening, but do not usually signify any serious or life-threatening disease.
After acute vertigo settles, it is often followed by disequilibrium (diss-eck-will-IB-ree-um), an uneasy feeling of imbalance, as though one might be about to fall over.
In this stage, a vestibular physiotherapist assists patient to reduce dizziness and imbalance by employing exercises to re-train the brain. This is called Vestibular Rehabilitation or Vestibular Physiotherapy.
What is Vestibular Rehabilitation?
Vestibular physiotherapy is based on the concept that the very movements that make the patient dizzy can eventually relieve the symptoms through repetition. By repeatedly bombarding the brain with the incorrect messages, the brain is ultimately forced to adapt, accepting and reinterpreting the faulty signals as correct. When that happens, the symptoms subside.
Vestibular Rehabilitation consists of exercise programs designed for each patient individually. The exercises are simple and easy to perform to a point that many patients are skeptical at first that they can work. Most inner-ear disorders require 6 weeks to 18 months of physiotherapy. The program usually consists of one or two weekly sessions in the clinic to monitor and progress exercises as the patient improve, and once or twice daily practices at home and typically include:
Gaze stabilization exercises to improve the ability to focus on objects in the environment while moving head. This is important for activities of daily living such as reading signs when walking and driving, shopping in a mall or grocery store, playing sports….
Habituation exercises, like jumping, sitting up and lying down rapidly and turning in circles.
Balance retraining exercises such as standing on a thick piece of foam rubber or rocking board with eyes closed to force the brain to rely on information from the inner ear rather than messages from the eyes and the feet.
Depending on patient’s lifestyle or work, these exercises can be progressed to very advanced levels and include complex activities.
What is the success rate of Vestibular Rehabilitation?
Studies show that 85 percent of patients with inner-ear problems get at least partial relief from vestibular rehabilitation, and 30 percent recover completely. As the population ages and in part because dizziness is a major problem for the elderly, physiotherapists are increasingly being involved in this area of healthcare.
Although a very effective, drug-free, risk-free treatment, Vestibular Rehabilitation is not for everyone. Some inner-ear disorders require medication or surgery.
For more information visit VESTIBULAR DISORDER ASSOCIATION (VEDA), a non-profit organization that exists to provide information and support to people suffering from inner-ear balance disorders.at: