How Physiotherapy Can Help Treat Vertigo and Dizziness
June 1, 2016
Leanne Loranger, PT
Vertigo and dizziness can affect people of all ages and of both genders. Dizziness is a common complaint affecting more than 30% of people over the age of 65 and more than 50% of those over 85, with women being more commonly affected than men.1 Furthermore, 20% of people over the age of 60 experience dizziness that results in disability or affects their ability to complete their normal activities.1
Dizziness often leads to decreased confidence and self-esteem, and a fear of falls1 which in turn can lead to self-imposed activity limitations, a further decrease in independence, and depression. Individuals with dizziness are also at an increased risk of falls and experience more frequent hip and wrist fractures.1, 2
Normal balance relies on input from the eyes and the vestibular system, as well as nerve inputs from muscles and joints.1,3,4 These inputs are processed in the brain, which then determines the response needed to keep a person upright.1 All of this happens reflexively and without us being consciously aware of the balance system’s work to keep us on our feet.
Despite the simplicity of this explanation, it should be noted that the vestibular system and the body’s ability to receive and react to these inputs is very complex. If any one of these systems fails to function properly, it can lead to dizziness, loss of balance and falls.1,4
Some possible causes of dizziness
Peripheral vestibular dysfunction, (more commonly referred to as inner ear problems)
Often manifests as the feeling that the room is spinning or of being pulled sideways,1 but can also result in a general sense of being dizzy or unsteady.
Can lead to changes in the stimuli from the nerves and muscles of the neck, or instability in the neck,5 which can then result in dizziness.
Can also cause changes to the reflex that coordinates head and eye movements, resulting in vision changes and dizziness.6
Circulatory problems, including low blood pressure
Manifests as a feeling of lightheadedness or an impending faint or loss of consciousness (that feeling you get when you "stand up too fast").1
Other nervous system problems
Strokes, Multiple Sclerosis and migraines can also cause changes to the portions of the brain and spinal cord responsible for processing inputs from the peripheral vestibular system and other systems involved in balance, leading to dizziness.11
In as many as 40-80% of cases the cause of dizziness cannot be determined.1 Determining the cause of dizziness (when possible) and designing an appropriate treatment approach requires an assessment by a health-care professional, such as a physiotherapist trained in the management of dizziness and vestibular dysfunction.
What exactly is the vestibular system?
Each person has two peripheral vestibular systems, one on each side of the skull, located in the inner ear. The peripheral vestibular system is composed of three semicircular canals, the utricle and the saccule. The semicircular canals are situated along three planes of space and monitor turning movements of the head3 while the utricle and saccule monitor the head’s position in space (relative to gravity) and head movements along a straight path. The semicircular canals are filled with liquid; the utricle and saccule contain liquid and small crystals. When your head moves, the liquid and crystals move within the vestibular system, bending small hair-like nerve cells found inside the semicircular canals, utricle and saccule, thereby causing nerve inputs and the sensation of movement.4 If this nerve input is limited, or excessive, it can cause the sensation of vertigo.3
Are vertigo and dizziness the same thing?
Although people often use the terms vertigo and dizziness interchangeably, vertigo is a distinct subtype of dizziness characterized by the sensation of movement when no movement is occurring.1 Vertigo can be caused by changes to the peripheral vestibular system (the inner ear), or the central vestibular system (portions of the brain and spinal cord responsible for processing inputs from the vestibular system and other systems involved in balance).11
Vertigo is typically more severe than other types of dizziness, and may also be associated with symptoms of sweating, nausea and vomiting and pallor.1 People with vertigo may also complain of ataxia (staggering when walking), headache, a loss of neck flexibility, and nystagmus (twitching eye movements) when the head is placed in certain positions.1
The specific symptoms that a person experiences will depend on the cause of their vertigo, for example vertigo arising from the peripheral vestibular system is typically caused by an abrupt change in nerve output from one vestibular system compared to the other. The sudden onset of this uneven output causes vertigo, nystagmus, imbalance and nausea.12
How are vertigo and dizziness treated?
Although vertigo has a high proportion of spontaneous resolution,3 there are treatments available to speed recovery and to help those with long-standing symptoms. Treatment also depends on the cause of the patient’s symptoms.
One form of vertigo, Benign Paroxysmal Positional Vertigo (BPPV) is thought to result from crystals being in the canals where they’re not supposed to be, causing excessive input to the nervous system that the brain interprets as movement when none is occurring. The treatment is to try to reposition the crystals. A common approach is the Epley Maneuver, in which the physiotherapist guides the patient through a series of movements of the head and body to attempt to reposition the crystals. The Epley Maneuver has been found to be effective in the treatment of BPPV.3,7
Another approach to treatment of vertigo attempts to train the brain to be less responsive to the vestibular inputs that are perceived as dizziness. Although less commonly used than the Epley Maneuver, Brandt-Daroff exercises can reduce the symptoms of vertigo by helping patients to accommodate to and ultimately ignore (or at least become less responsive to) the inaccurate nervous system inputs that are causing the dizziness.7 Brandt-Daroff exercises may be used when the Epley Maneuver is not effective in resolving the person’s symptoms.
In cases where dizziness or vertigo occurs following a concussion or motor vehicle accident, the cause of dizziness may be due to direct injury to the vestibular system itself,5 injury to the neck,8 or may be due to changes in how the brain processes nervous system inputs that contribute to balance. Due to the large number of nervous system inputs that arise from the neck, there is some evidence to suggest that the first approach to treating the dizziness following an injury should be to assess and treat the neck problem.9 However, if treatment to the neck does not result in a cure or reduction in dizziness, a further assessment and treatment of the vestibular system may be needed.
What about vestibular rehabilitation or balance training in general?
Some evidence suggests exercises that challenge the balance of individuals with central or peripheral vestibular dysfunction can result in improved balance and decreased falls risk,2,10,11 particularly when the exercises provoke the patient’s symptoms of vertigo or dizziness.1,8 By participating in such exercise programs, patients adapt to their symptoms of dizziness, the brain becomes able to adapt to the stimuli that are interpreted as dizziness, and the patient’s confidence and general activity levels are improved.8,10 As with many areas of physiotherapy practice, more research is needed to define which patients benefit the most from vestibular rehabilitation3 and what activities should be included in vestibular rehabilitation.
Due to the complexity of the vestibular system and the many potential causes of dizziness and vertigo, treatment cannot take a one-size-fits-all approach. If you are experiencing vertigo or dizziness that is limiting your daily activities or making you fearful of falling, physiotherapy can help to identify the source of the problem and provide tailored treatment to help manage your symptoms and improve your ability to function.
Holmes S, Padgham ND. A review of the burden of vertigo. Journal of Clinical Nursing 2011; 20:2690-2701.
Hansson EE, Mansson N-O, Ringsberg KA, Hakansson A. Falls among dizzy patients in primary healthcare: An intervention study with control group. International Journal of Rehabilitation Research 2008; 31(1):51-57.
Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo (Review). Cochrane Database of Systematic Reviews 2014; 12: Art.No.: CD003162. DOI: 10.1002/14651858.CD003162.pub3.
Kovar M, Jepson T, Jones S. Diagnosing and treating benign paroxysmal positional vertigo. Journal of Gerontological Nursing 2006; December:22-27.
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Purves D, Augusting GJ, Fitzpatrick D, Katz LC, LaMantia AS, McNamara JO, Williams SM. Central vestibular pathways: Eye, head, and body reflexes. In: Sunderland MA, ed. Neuroscience (2nd ed.). Sinauer Associates. Available from: http://www.ncbi.nlm.nih.gov/books/NBK10987/
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Reid SA, Rivett DA, Katekar MG, Callister R. Sustained natural apophyseal glides (SNAGs) are an effective treatment for cervicogenic dizziness. Manual Therapy 2008; 13:357-366.
McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database of Systematic Reviews 2015; Issue 1. Art. No.: CD005397. DOI: 10.1002/14651858.CD005397.pub4.
Farrell L. Peripheral versus central vestibular disorders. American Physical Therapy Association, Section on Neurology n.d. Available from: http://www.neuropt.org/docs/vsig-physician-fact-sheets/peripheral-vs-central-vestibular-disorders.pdf?sfvrsn=2 Retrieved on May 25, 2016.
Tonks, B. Physiotherapy, Dizziness and Vertigo. Email to Leanne Loranger, email@example.com. 2016 May 23 [cited on May 31, 2016].