Vertigo and dizziness

How to differentiate vertigo from dizziness?

Vertigo is a sensation where you feel yourself spinning in your environment (internal vertigo) or when the environment around you is spinning (external vertigo). The classic example of vertigo is when you feel like the walls around you are spinning.

On the other hand, dizziness is a very vague term to describe a feeling of unease in space (not feeling well in the space around you). The description can vary from person to person.

Here are some examples of sensations that are considered dizziness:

• Feeling disoriented
• Feeling lightheaded
• Feeling like you're floating on a cloud
• Feeling unstable or having a sensation of intoxication

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Vertigo (BPPV and other types of vertigo)

There are different types of vertigo. The most common is BPPV (benign paroxysmal positional vertigo).

What is benign paroxysmal positional vertigo (BPPV)?

It is a type of vertigo that is triggered by head movements.

It is the most common type of vertigo, caused by the displacement of small crystals (called otoconia) in the inner ear, where our balance system is located.

When you move your head, small crystals and other tiny debris shift, overstimulating your balance system and causing the sensation of vertigo.

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What are the symptoms of BPPV?

• Le vertige est habituellement très intense et de courte durée (< 1 minute)
• It is triggered by a sudden change in head position, such as:
  
  • Getting up or lying down in bed
  • Bending forward or standing up
  • Looking up or turning over in bed
• Vertigo can be accompanied by other symptoms such as
  
  • Nausea or vomiting
  • Loss of balance
  • Other complaints that vary from person to person.
• Often, people will completely avoid the positions or movements that triggered vertigo to prevent experiencing it again.

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What are the warning signs that require medical attention?

The presence of certain signs and symptoms should prompt you to seek immediate medical attention at the emergency room or from a doctor. These include:

• Loss of consciousness
• Dizziness upon physical exertion
• Vertigo with severe headaches
• Hearing loss
• Significant balance problems (falling as soon as you stand up)
• Projectile vomiting (forceful expulsion of vomit)

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What are the causes of BPPV?

• 10-30% of cases: BPPV can develop following trauma (such as a concussion or any other injury to the head or neck).
• 5-25% of cases: BPPV can also result from a migraine, labyrinthitis, neuronitis, or Meniere's disease.
• 60-80% of cases: BPPV can also be idiopathic, meaning it has no known cause.

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How is BPPV diagnosed?

The physiotherapist diagnoses BPPV based on the history of your symptoms and a clinical examination.

The clinical examination includes specific positional vertigo tests, an assessment of the oculomotor system (eye coordination), and a neck evaluation.

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When should you see a physiotherapist for BPPV?

You should see a physiotherapist if you have symptoms as described above, or if your doctor has already ruled out any other possible causes of your vertigo.

You should see a physiotherapist who has expertise and adequate training to assess and treat BPPV; that is, a physiotherapist with expertise in vestibular physiotherapy.

You do not need to see a doctor before consulting a physiotherapist. If your condition requires you to see a doctor, the physiotherapist will be able to tell you.

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What physiotherapy treatments are available for BPPV?

Once a diagnosis of BPPV is made, in-clinic maneuvers performed with your physiotherapist, along with a series of specific exercises to do at home, will help resolve the problem.

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What can you do at home for BPPV?

While waiting to see a physiotherapist, simply avoid the positions that trigger vertigo if you find your symptoms are too strong and unpleasant.

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What are the other types of vertigo besides BPPV?

Central positional vertigo is very similar to BPPV, but rarer. Neurological symptoms such as the following are often reported along with the vertigo:

• Headaches
• Significant weakness
• Unstable gait

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Some facts and statistics about vertigo to debunk some myths…

• There are three semicircular canals in the inner ear. In 60 to 90% of BPPV cases, the posterior canal is affected, in 5 to 20% the horizontal canal, and in 1 to 10% the anterior canal.
• One or more canals can be affected at the same time during BPPV, and the signs and symptoms will differ depending on the canal affected.
• Trauma increases the risk of having multiple canals affected and causing BPPV.
• Women are three times more likely than men to develop BPPV.

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Dizziness

There are various causes of dizziness.
In physiotherapy, cervicogenic dizziness is the most common type we see.
Dizziness can also be caused by an anxiety disorder, orthostatic hypotension, certain medications, and many other less frequent causes.

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What is cervicogenic dizziness?

It is dizziness caused by a problem related to the cervical spine.

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What are the symptoms of cervicogenic dizziness?

Dizziness does not feel different when it originates from a neck problem versus another source. The description can vary from person to person, such as:

• Feeling disoriented
• Feeling lightheaded
• Feeling like you're floating on a cloud
• Feeling unstable or having a sensation of intoxication

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In the specific case of cervicogenic dizziness, other signs and symptoms are often present, such as:

• Neck pain or stiffness
• Headaches
• Reduced neck mobility
• Dizziness that occurs after prolonged neck postures (at the computer, while driving, or while reading)

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What are the causes of cervicogenic dizziness?

The exact cause is still not well understood. One explanation is a poor perception of the neck in space by our brain (poor neck proprioception).

Neck pain and headaches are also factors associated with dizziness. Therefore, this type of dizziness can occur after an episode of neck pain or after whiplash from a car accident, for example.

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How is cervicogenic dizziness diagnosed?

Your physiotherapist will diagnose cervicogenic dizziness based on your symptom history and a clinical examination.

The clinical examination will include:

• Identifying neck positions and postures that trigger dizziness
• Assessing neck mobility
• Performing specific tests
• Note that a deficit in the oculomotor system (eye coordination) or vestibular system (balance system) can also contribute to cervicogenic dizziness. An evaluation of these two systems will therefore also be included to determine the cause.

There is no specific test for diagnosis. From a medical standpoint, it is mainly a diagnosis of exclusion, meaning that all other possible causes have been eliminated.

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When should I see a physiotherapist for dizziness?

You should consult a physiotherapist if you have symptoms as described above, or if your doctor has already ruled out any other cause that could explain your dizziness.

You do not need to see a doctor before consulting a physiotherapist. If your condition requires you to see a doctor, the physiotherapist will be able to tell you.

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What are the physiotherapy treatments for cervicogenic dizziness?

Your physiotherapist will assess the following:

• Your joint mobility
• The gliding of your nerves
• Your postural habits
• The quality of your movements
• Your strength and stability
• The oculomotor system
• The vestibular system

Based on the evaluation results, the physiotherapist will mobilize the joints and nerves in your neck to reduce pain and improve movement. They will give you specific exercises to do at home to address the cause of the problem. If the oculomotor or vestibular system is involved, your physiotherapist will also include treatment of these two systems.

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Other information on vertigo and dizziness

What are the other possible causes of vertigo or dizziness?
Some other conditions can cause vertigo or dizziness, such as:

• Vestibular pathologies
• Cardiac problems (orthostatic hypotension, arrhythmias)
• Psychiatric issues (anxiety disorders, conversion disorders)
• Other causes: brain tumors, multiple sclerosis, migraines, encephalopathy, Arnold-Chiari malformation, and drug or alcohol intoxication.

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What is the link between anxiety and vertigo and dizziness issues?

Vertigo and dizziness are symptoms that often worry people because it is unpleasant to experience them.

This concern can lead people to experience a lot of anxiety and become hypervigilant, paying close attention to every symptom they feel.

"All the body's signals can then become a potential threat to the anxious person. In some cases, anxiety can even become more problematic than the vestibular problem itself."

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Sources

• Ogun OA, Janky KL, Cohn ES, Büki B, Lundberg YW. Gender-based comorbidity in benign paroxysmal positional vertigo. PLoS One. 2014 Sep 4;9(9):e105546.
• Shim DB, Song CE, Jung EJ, Ko KM, Park JW, Song MH. Benign paroxysmal positional vertigo with simultaneous involvement of multiple semicircular canals. Korean journal of audiology. 2014 Dec;18(3):126.
• Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, Chalian AA, Desmond AL, Earll JM, Fife TD, Fuller DC. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngology–Head and Neck Surgery. 2008 Nov;139(5_suppl):47-81.
• Brandt T. Vertigo: its multisensory syndromes. Springer Science & Business Media; 2013 Jun 29.
• Reiley AS, Vickory FM, Funderburg SE, Cesario RA, Clendaniel RA. How to diagnose cervicogenic dizziness. Archives of physiotherapy. 2017 Dec 1;7(1):12.

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