Vertigo – Can a physiotherapist help?

90% of people who present to a physiotherapist complain of pain as their primary symptom. Not many people think to present to physiotherapy for their dizziness and even then, is physiotherapy warranted for the dizziness they are experiencing?

Dizziness accounts for an estimated five percent of primary care clinic visits and can be very difficult to diagnose. A final diagnosis is not obtained in about 20 percent of cases. The patient history can generally classify dizziness into one of four categories: vertigo (false sense of motion, possibly spinning sensation), disequilibrium (off-balance or wobbly), presyncope (feeling of losing consciousness or blacking out), or light headedness (vague symptoms, possibly feeling disconnected with the environment). This article will focus on vertigo only, more specifically BPPV.

The main causes of vertigo are benign paroxysmal positional vertigo (BPPV), Meniere disease, vestibular neuritis and labyrinthitis. The most common causes of vertigo are peripheral vestibular disorders, but central nervous system disorders must be excluded. For example, It is important to know that BPPV will NOT give you constant dizziness that is unaffected by movement or a change in position. It will NOT affect your hearing or produce fainting, headache or neurological symptoms such as numbness, pins and needles, trouble speaking or trouble coordinating your movements. Physiotherapists are able to treat BPPV but if you have any of the symptoms above, it is important to consult with your GP to exclude other pathologies.

So what is BPPV?
If we break down the four words involved in the diagnosis, benign (it is not life-threatening), paroxysmal (it comes in sudden, brief spells), positional (triggered by certain head positions or movements), vertigo (a false sense of rotational movement), is easy to make meaning of.

What is physically happening?
BPPV occurs when some of the calcium carbonate crystals (otoconia) that are normally embedded in gel in the utricle (inner ear) become dislodged and migrate into one or more of the 3 fluid-filled semicircular canals, where they are not supposed to be. When enough of these particles accumulate in one of the canals they interfere with the normal fluid movement that these canals use to sense head motion, causing the inner ear to send false signals to the brain.

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When the fluid moves, the crystals excite nerve endings in the canal and this sends a message to the brain that the head is moving, even though it isn’t. This false information does not match with what the other ear is sensing, with what the eyes are seeing, or with what the muscles and joints are doing, and this mismatched information is perceived by the brain as a spinning sensation. When someone with BPPV has their head moved into a position that makes the dislodged crystals to move within a canal, the error signals cause the eyes to move in a very specific pattern, called “nystagmus” which is an involuntary, rapid and repetitive movement of the eyes. Imagine the eyes shaking side to side!

There are two forms of BPPV, canalithiasis and cupulolithiasis. Canalithiasis is the most common and occurs when otoconia are moving within the semicircular canal, causing vertigo and nystagmus that resolves within 60 seconds. Cupulolithiasis occurs when otoconia adhere to the cupula and cause vertigo and nystagmus that persist for a longer period of time.

Symptoms of BPPV
The main symptom of BPPV is vertigo induced by a change in head position with respect to gravity. Patients typically develop vertigo when getting out of bed, rolling over in bed, tilting their head back, for example to look up to shelves, or bending forward, for example when fastening their shoes. However, the symptoms of BPPV may vary among patients, and may manifest with nonspecific dizziness, postural instability, light headedness, and nausea. The vertigo in BPPV is typically intermittent and positioning dependent. The vertigo is mostly transient in BPPV, its duration correlating well with the duration of the positioning nystagmus, which usually resolves within 30 seconds in posterior canal BPPV. However, the duration is relatively longer (sometimes lasting longer than 1 minute) in horizontal canal BPPV.

How do physiotherapists diagnose?
The Dix-Hallpike or Roll Tests involve moving the head into specific orientations, which allow gravity to move the dislodged crystals and trigger the vertigo while the practitioner watches for the nystagmus. The nystagmus will have different characteristics that allow a physiotherapist to identify which ear the displaced crystals are in, and which canal(s) they have moved into.

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So how do we get rid of it!?
There are a series of treatments that a physiotherapist may use to treat BPPV (Epley, Semont, Brandt‐Daroff or Gans manoeuvres). The manoeuvre that is utilised depends on the results of the assessment and which canal(s) the crystals are inhabiting. They are understood to work by moving the canal debris out of the semicircular canal. For example, the Epley involves a series of four movements of the head and body from sitting to lying, rolling over and back to sitting.

The following is an example treatment of a patient with BPPV affecting the right ear:

First, a Dix–Hallpike test is performed with the patient’s head rotated 45 degrees toward the right ear and the neck slightly extended with the chin pointed slightly upward. This position results in the patient’s head hanging to the right.

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Once the vertigo and nystagmus provoked by the Dix–Hallpike test cease, the patient’s head is rotated about the longitudinal body axis until the left ear is down.

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Then the head and body are further rotated until the head is face down and the patient is lying on his/her left.

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The vertex of the head is kept tilted downward throughout the rotation. The manoeuvre usually provokes brief vertigo and a small percentage of people may vomit so a bucket is usually handy to have nearby! The patient should be kept in the final, facedown position for about 10 to 15 seconds. With the head kept turned toward the left shoulder, the patient is brought into the seated position. Once the patient is upright, the head is tilted so that the chin is pointed slightly downward.

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Conclusion
A referral to a physiotherapist with experience treating BPPV can lead to quick resolution of symptoms and can also significantly reduce secondary complications such as anxiety, falls, and decreased quality of life. If any of your family members or friends are experiencing symptoms similar to above mentioned, please contact your physiotherapist today!

References
Baloh RW, Jacobson K, Honrubia V. Horizontal semi circular canal variant of benign positional vertigo. Neurology. 1993;43:2542–2549.

Blatt PJ, Georgakakis GA, Herdman SJ, Clendaniel RA, Tusa RJ. The effect of the canalith repositioning maneuver on resolving postural instability in patients with benign paroxysmal positional vertigo. Am J Otol. 2000;21:356–363.

Giacomini PG, Alessandrini M, Magrini A. Long-term postural abnormalities in benign paroxysmal positional vertigo. ORL J Otorhinolaryngol Relat Spec. 2002;64:237–241

Am Fam Physician. 2010 Aug 15;82(4):361-8, 369. Dizziness: a diagnostic approach. Post RE1, Dickerson LM.

Neurologist. 2008 Nov;14(6):355-64. doi: 10.1097/NRL.0b013e31817533a3. Central vertigo and dizziness: epidemiology, differential diagnosis, and common causes. Karatas M1.

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