In this blog we will look at an extremely common problem and attempt to provide some answers to a very common question that many of our physiotherapy patients have: "why do I get dizzy?" Although this is a simple question, as ever in the world of physiotherapy the answer is not so simple and in fact dizziness is a very difficult area in which to be certain of the exact causes.

Here we will examine a common cause of dizziness which can respond well to physiotherapy - vestibular dysfunction.

 Dizziness is an extremely common complaint and some studies have shown that between 15 - 50% of adults suffer with it and that it is one of the most common complaints for patients over the age of 75, with it possibly accounting for up to 18% of GP visits in the over 85s, which would seem to suggest that as we age we become more prone to episodes of dizziness. This increase in dizziness as people age certainly matches my own clinical experience and many of the older patients that I see often describe episodes of dizziness and how they had a fall after going dizzy.

Balance is a complex process and the brain receives information about where you are in space from several sources: firstly the eyes, secondly the inner ear (vestibular system) and finally feedback from the muscles (proprioception), this is then processed by the brain to provide control to our eyes (oculo-motor function) our postural muscles, control to any motor skills required at the time, an awareness of where our head and body are in space and finally an awareness of any movement.

Problems in any one of these systems will likely affect our sense of balance and motion and can result in an episode of dizziness and possibly a feeling of vertigo. We shall focus on the vestibular system and how it sometimes causes problems as it can respond well to physiotherapy and patients with true inner ear vestibular balance problems can gain great improvements from physiotherapy.

The inner ear is a wonder of biomechanical engineering and enables you to sense direction of movement and speed of acceleration if any direction. It is made up of the labyrinth in which reside the three semi-circular canals (horizontal, anterior & posterior). The semi-circular canals provide information about head acceleration in 3 planes - nodding, rotating and tilting the head side to side, this is done by sensing the movement of fluid inside each of the canals. This information is then used by the brain to keep the eye still during head movement - the vestibular ocular reflex (VOR).

However these canals are not sufficient to provide a full vestibular system as they can not sense up and down and forward and back movements of the whole body, importantly they are not gravity sensitive. This ability to sense forward and back and up and down movements of the whole body is provided by the otoliths of which there are two - the saccule and utricle. This occurs by sensing of movement of hair cells inside the otoliths and dense crystals called otoconia. These two separate mechanisms - the semi-circular canals and otoliths enable us to sense the movement of the body in all directions and any accompanying head movements. This is why when you are in a lift and despite there being no change in what you are seeing you can still sense when the lift moves up or down.

The information from the vestibular system - sensing movements of the body and rotation or movements of the head is compared with what the eyes are seeing and the muscles of the body are sensing to give us a an idea and feeling of orientation. For example if you tilt your head to one side information from the vestibular system, eyes and muscles are all compared to tell you that your body has remained in the same position and it is only your head that has moved! This all happens incredibly quickly and without any thinking about it. Now, this sounds like a perfect system and you may be thinking if it all works so well why do people ever get dizzy or lose balance or feel vertigo? Well, there are two main dysfunctions of the vestibular system that can occur.

Firstly there is benign paroxysmal positional vertigo - usually referred to as BPPV for short. This occurs when some of the crystals (otoconia) from the otoliths become detached and end up in the semi-circular canal. GPs will often explain to patients that they have "crystals in the ear" when they are describing the causes for BPPV and why the patient has become dizzy. As mentioned before the canals only sense head movement and not whole body up and down movements, however when the otoconia (crystals) enter the canals they become gravity and whole body movement sensitive. This causes patients to feel as if their whole body is moving when they tilt their head. For example if a patient looks up the crystals will move and instead of simply feeling their head moving up and their body remaining still, they will now feel as if they are moving backwards and will probably stagger back to stop this feeling of falling over. The brain as this is happening compares what is happening in the vestibular system with input from the eyes and the muscles and unsurprisingly becomes confused which patients will experience as dizziness. Typically someone with BPPV will describe brief episodes of dizziness that occur when the patient looks up or rolls over in bed. BPPV will usually respond very well to physiotherapy and is commonly treated using the Epley manoeuvre.

The second common cause of dizziness is vestibular neuritis, actually this causes episodes of vertigo rather than dizziness but sometimes patients will call it dizziness. Medically the rem means inflammation of the vestibular nerve but it is nowadays thought to be a pathology of the labyrinth rather than just an inflammation of the vestibular nerve. It is thought that it can occur after a virus and has been linked to the herpes virus. Whatever the exact cause patients will usually experience a specific and very intense episode of vertigo during which the room and everything feels as if it is moving and they will often be sick as a result. This is probably the defining difference between a patient presenting with BPPV and the residual effects of vestibular neuritis. Often symptoms will completely resolve over a period of weeks but in some patients they may persist at a low level for a long period and these patients would certainly benefit from physiotherapy and vestibular rehabilitation in the form of exercises that improve the patient's balance, awareness of head position and eye control.

A word of warning for anyone reading this blog: if you or anyone you know is experiencing dizziness then it is important that you seek a medical assessment as there are many potential causes of dizziness and vertigo, some of which are serious and will require urgent medical treatment. This blog only looks at dysfunctions of the vestibular system and how this can affect balance and may cause dizziness. Having said that, if you have seen your GP and have had any serious pathologies or illnesses ruled out and you think you or a relative may have a vestibular problem that is causing  episodes of dizziness then please do get in touch to book an assessment as physiotherapy and vestibular rehabilitation can make a large difference to this condition.

We are a home visit physiotherapy service based in Lichfield (Staffordshire) and serving anywhere within a 25 minute drive, including areas such as Sutton Coldfield, Tamworth, Burntwood, Rugeley, Cannock and Walsall. If you would like further information regarding our physiotherapy service then please get in touch on 0788 428 1623 or email us at enquiries@threespiresphysiotherapy.co.uk.