The dizzy patient
Dizziness can significantly impact our participation in everyday activities. It is important to determine what type of dizziness you are feeling. Vertigo is a type of dizziness where it feels like the room is spinning and can be far more debilitating. Vertigo can be caused by damage or changes to the vestibular system. Did you know, your physio can help treat your vertigo?
The Vestibular system
The vestibular system is located within our inner ear and contributes to our balance system and senses the location of our head in space with movement (which is why it feels like the room is spinning when experiencing vertigo).
There are 5 main vestibular disorders:
1. BPPV: This is a disorder of the inner ear canals characterised by episodes of vertigo with change in head movements. It is caused by “crystals” in the semicircular ear canals called otoliths, which become dislodges and settle within the endolymph of the semicircular canals. With head movements, the crystal moves within the fluid, this is unmatched with the opposite ear and results in the feeling of the room spinning, dizziness and swaying which is why head movements bring on symptoms (Palmeri & Kumar, 2021).
2. Vestibular neuritis/labyrinthitis: This is a type of dizziness due to a viral infection and inflammation of the vestibular nerve and/or ganglion. Symptoms include vertigo, nausea, and gait imbalance. Labyrinthitis is the combination of the same symptoms of vestibular neuritis with the addition of hearing difficulties (Smith, Rider, Cen & Borger, 2021). Vestibular neuritis/ labyrinthitis accounts for 15% of all vertigo presentations (Hain,2021).
3. Meniere’s disease: Is a chronic vestibular disorder caused by a build-up of large amounts of a fluid (endolymph) in the inner ear. There is no cure and the cause is unknown. Symptoms include fluctuating hearing loss, ringing or pressure in the ears, eventually progressing to vertigo, nausea, and changes in walking due to decreased balance (Vestibular Disease Association, 2021).
4. Vestibular migraine: is a type of migraine that mainly presents with dizziness symptoms. Vestibular migraine is associated with nausea, vomiting, flushing, visual changes: blurring, flashing lights, difficulty focusing, concentrating and sensitivity to right lights (Meniere’s Society, 2021).
5. Acoustic Neuroma: These are slow growing non-malignant tumours of the 8th cranial nerve. Hearing loss is the most common symptom and affects 90% of patients. Vertigo only occurs in about 20% of cases and the feeling of unsteadiness and decreased balance is a more common symptom. (National Organisation for Rare Disorders, 2021).
We will be delving into BPPV, the most common vestibular disorder, accounting for over 50% of all cases.
Diagnosis of BPPV
It is important obtain a good history and try to understand the nature of your symptoms to determine if it is BPPV. The physiotherapist will ask a series of questions about your dizziness and then conduct some neurological tests to rule out other conditions.
Room spinning commonly occurs with head movements: forwards movement, rolling in bed, head turns etc. These symptoms usually settle down after 30-60 seconds. A common test used to diagnose BPPV is called the Dix-Hallpike, which is a provocative test that brings on the symptoms (Palmari & Kumar, 2021). A positive Dix-Hallpike manoeuvre is diagnostic for posterior canal BPPV (Nguyen-Huynh, 2012).
Treatment of BPPV
A qualified physiotherapist with perform the Epley manoeuvre, which is the first-line treatment for posterior canal BPPV and can be done straight away from the end of the Dix Hallpike position. This involves a series of head and body positions for 30-60 seconds each position to allow the dislodged crystal to move out of the semicircular ear canals. This form of treatment can be very provocative some sometimes slower, gradual head, body and eye movement exercises can be given to help reduce symptoms.
Habituation exercises: this involves specific repetitive movements to gently provoke the patients’ symptoms to desensitize their vestibular system to those movements. The patient performs these movements until reduces their symptoms of dizziness (Kundakci, Sultana, Taylor & Alshehri, 2018).
The Brandt-Daroff exercise is an example of a habituation exercise. You can do this at home to help treat your vertigo, however, is it more time consuming than the Epley’s Manoeuvre. To do the Brandt-Daroff exercise: Start in an upright, seated position. Move into the lying position on one side with your nose pointed up at about a 45-degree angle. Remain in this position for about 30 seconds (or until the vertigo subsides, whichever is longer). Then move back to the seated position. Repeat on the other side. This exercise should be performed 3x a day for 5 repetitions each side and for 10 minutes. The response rate at one week is only 25% and therefore should be continued for 2-3 weeks (Hain,2021)
Overall
It is recommended to see a physiotherapist to be diagnosed correctly. They will prescribe habituation exercises that are safe for the individual. Some exercises may not be suited for the elderly, including rising quickly as it can cause orthostatic hypotension and potentially a fall. Your physiotherapist will educate you and can guide you in the right direction. Evidence shows that habituation exercises are a safe and effective method to treat vertigo symptoms within 4-6 weeks and reduces the need for unnecessary medication (Han, Song & Kim, 2011).
By Priyansh Narayan, student at Exercise Thought
References:
Hain., T. (2021). HOME TREATMENTS OF BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV). Retrieved from https://dizziness-and-balance.com/disorders/bppv/home/home-pc.html
Han, B. I., Song, H. S., & Kim, J. S. (2011). Vestibular rehabilitation therapy: review of indications, mechanisms, andkey exercises. Journal of clinical neurology (Seoul, Korea), 7(4), 184–196. https://doi.org/10.3988/jcn.2011.7.4.184
Kundakci, B., Sultana, A., Taylor, A. J., & Alshehri, M. A. (2018). The effectiveness of exercise-based vestibularrehabilitation in adult patients with chronic dizziness: A systematic review. F1000Research, 7, 276.https://doi.org/10.12688/f1000research.14089.1
Meniere’s Society. (2021). What is Vestibular Migraine? Retrieved from https://www.menieres.org.uk/information-andsupport/symptoms-and-conditions/migraine-associated-vertigo
National Organisation for Rare Disorders. (2021). Acoustic Neuroma. Retrieved from https://rarediseases.org/rarediseases/acoustic-neuroma/
Nguyen-Huynh A. T. (2012). Evidence-based practice: management of vertigo. Otolaryngologic clinics of North America, 45(5), 925–940. https://doi.org/10.1016/j.otc.2012.06.001
Palmeri R, Kumar A. Benign Paroxysmal Positional Vertigo. [Updated 2021 Jun 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470308/
Smith, T., Rider, J., Cen, S., & Borger, J. (2021). Vestibular Neuronitis. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2021 Jan-. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK549866/
Vestibular Disease Association. (2021). Menieres disease. Retrieved from https://vestibular.org/article/diagnosistreatment/types-of-vestibular-disorders/menieres-disease/