Dizziness, Vertigo and Balance
I am not exaggerating when I say that it can be a difficult task to explain your symptoms. How do you tell your health practitioner exactly what happened or how you feel? This is especially the case with dizziness related problems. Dizziness means different things to different people.
How will I help you?
When you are sent to my practice, we first will have an intake during which you can take your time to explain your story to me. Together we will define your symptoms. If necessary, I will ask you some specific questions and perform a series of tests which will result in a hypothesis or diagnosis. The actual treatment of dizziness depends on the cause and on your symptoms. Together we will set up an individual treatment plan to improve your situation or resolve your problem.
What is dizziness?
Dizziness is very often the general term patients use when describing their symptoms. In medical literature, dizziness is described as a sensation of lightheadedness, faintness or unsteadiness. Some patients feel like they are constantly walking on a boat or like they drank one glass of red wine too many. Sometimes this is associated with a ‘cotton wool’ feeling in the head, also known as ‘brain fog’. But when patients speak about a whirling and spinning sensation, a feeling that the person or the world is moving when it is not, we speak about vertigo. In both cases, this may lead to unsteadiness, loss of balance or spatial disorientation.
How do we keep our balance?
We don’t often think about how we can keep our balance, but it’s an incredible ingenious system.
Let’s try to explain this as simply as possible. Your body’s balance system relies on three senses. You can keep your balance through vision to see where you are going, your vestibular system (the balance organ in your inner ear, that gives out signals when your head moves) and proprioception (touch sensors in your body that allow you to feel where you are going). The information from these three systems is integrated and processed by the brainstem, which tells the eyes to maintain a steady vision and the muscles to maintain posture and balance.
When does dizziness occur?
When you experience dizziness, vertigo and disequilibrium, there might be something wrong with one or more of these sensory systems. In this case we speak about a vestibular disorder, which can be of peripheral or central origin. We speak about peripheral disorders, when the structure that causes the problem is located in the inner ear. The most commonly diagnosed peripheral vestibular disorders include benign paroxysmal positional vertigo (BPVV), labyrinthitis, vestibular neuritis, Ménière’s disease, and secondary endolymphatic hydrops. You will find more information about BPPV in the chapter about vertigo.
A vestibular disorder is of central origin when the cause is located in the brain. This is less common than a peripheral disorder, and often caused by problems with the blood vessels in the brain. A central lesion can cause vertigo, but it’s not the most common symptom. Patients often complain about motion sensitivity and imbalance. Other typical symptoms are difficulty of speaking, disturbance or loss of vision, problems with coordination, attention and memory. Patients might as well have the feeling that they are pulled or pushed to one side (lateropulsion).
Other problems related to vestibular dysfunction include complications from ageing, autoimmune disorders, and allergies. As well anxiety and stress, they can cause or intensify your symptoms. An important overlooked stress-related cause of dizziness is hyperventilation. This is an anxiety-induced superficial breathing pattern, that can produce many symptoms including dizziness and vertigo.
What do I do when I suffer from dizziness?
If you suffer from vertigo or dizziness and it doesn’t go away by itself, then contact your general practitioner, who can decide to make an appointment with an ENT or write you a prescription and send you directly to me. An ENT is an ears, nose and throat doctor; in the French-speaking part of Switzerland, he or she is called an ORL or otorhinolaryngologist. If the dizziness is of central origin it’s important to see a doctor as quickly as possible.
If you have a spinning sensation in your head that gets suddenly provoked when you change positions, and when the real spinning last between 5 and 15 seconds, then you may have a BPPV. Typically you will notice this when you look up or down or roll over to one side in bed.
What is BPPV?
BPPV stands for Benign Paroxysmal Positional Vertigo. It's a mouthful for saying that it's vertigo that suddenly (paroxysmal) appears when you change your position. Which means that if the actual spinning is all the time there, it’s very likely not a BPPV and it could be another pathology, e.g. an inflammation in the inner ear. The 'benign' part means that you don't have to worry; it's just a mechanical problem. Still, vertigo can be very limiting for your daily activities and provokes quite a bit of anxiety in some patients.
So what happens exactly?
The answer lies in the vestibular labyrinth. You can see in the image underneath, inside the inner ear an organ with three arc-shaped structures. These are the three semicircular canals; they are filled with fluid and provide us with information about motion, body position and spatial orientation. When you move your head, then the fluid in these canals will move as well. At the end of each canal, you have little hair cells. When they are set in motion by the fluid, they will send a signal about the movement of your head to the brain.
Adjacent to these canals is a space that is called the vestibule, in here we find the utricle and saccule. These two otolith organs play another essential role in the detection of movement; they help to detect linear acceleration. So it tells your body when you move forwards, e.g. when you drive a car. Or when you move upwards and downwards, like in an elevator.
What's more important for this story, is that they have little particles embedded in a layer of gel, which are called otoconia. These tiny crystals can become dislodged from the gel and migrate into one or more of the 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, causing the inner ear to send false signals to the brain. At that moment, you will experience a spinning sensation. It usually lasts 5-15 seconds; the amount of time that the otoconia move through your canals. When they move freely through the canal, we speak about canalithiasis. Unfortunately, sometimes they might be stuck; in this case, you have a cupulolithiasis. The spinning sensation can last with the latter variation longer, up to minutes or more.
What can I do about it?
If your symptoms sound familiar with what I described before, then you can ask your doctor for a prescription for physical therapy. In the initial treatment session, I will first of all examine if you have a BPPV, and secondly in which canal(s) the crystals are stuck. After that, I will use some specific manoeuvers, to put these crystals back in the vestibule. Here they won't bother you anymore. Most of my patients feel immediately a lot better after a succeeded manoeuvre.
In the second session, I will control if the manoeuvre performed in the first session worked and if all symptoms are gone. Sometimes I have to repeat the manoeuvre a second or third time. In some cases, the manoeuvre worked, but there can be other causes that provoke dizziness or vertigo.
Work in progress..
It's 3 a.m., and you suddenly wake up and notice a beep in one of your ears. Nervously you get out of bed, walk to the kitchen, drink a glass of water and wait for this annoying sound to diminish. Tinnitus (or in French: acouphène) is often experienced as something scary and intrusive. It's understandable because out of nowhere; there is suddenly a sound in your head that was not there before. And it's not in your imagination. So what is going on here?
What is tinnitus?
Tinnitus is the perception of sound in the absence of external sounds. Some of my patients tell me during the initial visit that they suddenly hear an annoying sound in one or two ears. Others tell me that they have this noise for many years, but that it only recently started to bother them. There are many different ways how patients experience this sound, frequently they describe a beeping, ringing, humming, hissing or whirring. In some rare cases, they speak about a whooshing sound with every heartbeat or mention a cracking or metallic sound. Scientifically we call every sound that is in your ear tinnitus. For half of these people, this is associated with a high sensitivity to sounds; which we call hyperacusis.
It might be likely that you know someone in your surroundings with tinnitus because it is quite common. I think we all know the sensation of a little ringing in the ear for a few seconds. But in the case of about 15% of the adult population, this ringing can stay for 3-6 months, or even longer. Only a small percentage of this group experiences tinnitus as moderately or very bothersome. And for these people, life can become a big struggle.
They can develop physical symptoms that often result in restlessness, tenseness, a lack of energy and tiredness. Tinnitus can lead to many mental problems such as sadness, anxiety, depression or hopelessness. All these symptoms have a negative influence on the experience of tinnitus.
We might as well notice some behavioural changes. Everyday activities like reading a book or listening to music will require more attention. People affected will often avoid places like a bar or restaurant, because the noise disturbs them, in the case of hyperacusis, or because they think it will get worse, in the case of tinnitus. This avoidance behaviour increases the focus on the tinnitus, giving it more and more importance. This might increase the perception of the tinnitus even more and in the long run lead to social isolation.
What causes tinnitus?
Until 10-15 years ago, scientists thought that hearing loss was the cause of tinnitus. The hair cells in the hearing organ (cochlea) in the inner ear would be damaged, broken or bend. Possible reasons for this could be loud noises, toxic medication or through natural ageing (presbycusis). The hair cells would transmit insufficient and incorrect information to the brain, which would wrongly interpret it as a sound, like a 'phantom sound'.
Nowadays, there are strong doubts about this theory. It is true that hearing loss plays an important role in the appearance of tinnitus, but not quite in the way as was initially presumed.
Because of the damaged hair cells, less information is sent from the inner ear to the brain, more precisely to the part of the brain that processes auditory information, the auditory cortex. You may think that less information means that the brain will have to work less, but the opposite is true. The brain needs to work harder and might increase its awareness to process the information transmitted by the inner ear. In other words, if the ear doesn't talk enough to the central auditory system, then these central nerve cells start to 'chatter' in an overactive way. This abnormal overactivity can result in tinnitus. However, many people without hearing loss, also have developed tinnitus.
Is there a cure for tinnitus?
This answer is not simple, although there are several treatments that can alleviate or reduce the tinnitus in some patients, there is still no universal cure. The problem that scientists now deal with is that there are different sub-types of tinnitus, there are several medical conditions associated with tinnitus. The logical consequence is that there isn't one specific treatment or magic pill that will cure everybody from their symptoms.
In the first place, there is a distinction between subjective and objective tinnitus. Most people suffer from subjective tinnitus, which means that only the patient can hear the sound. On the opposite, objective tinnitus can be perceived by the physician. This would be the case with objective pulsatile tinnitus, which is a whooshing noise, usually, with the same rhythm as your heartbeat, that could be heard by your doctor with a stethoscope. It is caused by an increased blood flow in a small artery in the inner ear. There is also an objective sound that can be caused by the twitching of one or two minuscule muscles in the middle ear. This distinctive form is called middle ear tinnitus.
Another sub-type of tinnitus is syndromic tinnitus. It can be caused by otosclerosis (problem with one of the hearing bones in the inner ear), an acoustic neuroma (a tumour on the auditory nerve) or Menière's disease (abnormal amount of fluid in the inner ear).
Which steps should I take for a treatment?
First of all, you should visit your generalist. He might examine your ears with an otoscope, which is a light source with a magnifier that shines into the ear canal. It shows if there is any superficial wax that needs cleaning or if there is an ear infection. Some house doctors might treat these conditions themselves, Or they sent you to an ear, nose and throat doctor (ENT) for further investigation. The ENT will try to find out possible causes for your tinnitus. You will undergo a hearing test; you will sit in a soundproof room with headphones on, you will hear sounds of higher and lower frequencies.
About half of the patients will have an IRM scan, usually to exclude an acoustic neuroma. This is a benign, usually slow-growing tumour that develops from the balance and hearing nerves. But don't worry, most people will have a negative test. A tiny group will have a blood test in case of pulsatile tinnitus, usually to exclude anaemia (lack of red blood cells) and thyroid problems.
What can a physiotherapist do for tinnitus?
There is one sub-type of tinnitus which I haven't mentioned yet, which can be treated by manual therapy and exercises, which is called somatosensory tinnitus. In this case, we establish that there is a relationship between the increased tension of the muscles from the cervical spine, the jaw muscles, the shoulder girdle and the intensity of the tinnitus. Physiotherapy helps in treating the painful muscular points, mobilising the upper cervical spine and providing home exercises.
Even if there is no confirmation of somatosensory tinnitus, there still are various ways to cope with tinnitus. The most common treatments that have proved to be beneficial are; understanding tinnitus, several talking therapies and the use of neuroplasticity. Sound therapy can be useful in the case of severe tinnitus. In my treatment, I will explain more in detail about the origin of tinnitus and answer possible questions. Together we will set up a treatment plan and figure out why your tinnitus is bothering you. We discuss the different treatment options and establish which ones will suit your needs.
What is the prognosis of tinnitus?
Wrong information plays a critical role in the experience of tinnitus. Too often I encounter people in my praxis that received the message that they 'just have to live with tinnitus’. In a certain way, this might be true, but there is a lot to learn about how you can live with it. And this means that eventually, 95% of the people will experience a significant decrease in their symptoms.
Tinnitus and hyperacusis are not an enduring problem for everyone. Most patients experience a decrease in the intensity of their symptoms within the first half-year. If people develop a strong emotional reaction to tinnitus in the first weeks or months, it might take considerably longer for them to accommodate those issues. The goal is to keep calm so that the auditory cortex calms down. The goal is not to experience tinnitus, as something terrible and threatening. Fear and anxiety work in the brain as a sort of amplifier. The limbic system, which is the part of the brain that deals with emotions, is often overactive in anxious patients.
In the physiotherapy session, you will learn through breathing and meditation exercises to tune this part of the brain down and experience tinnitus as less bothersome.
If you have further questions feel free to contact me.
Work in progress, more later.
Musculoskeletal conditions comprise more than 150 diagnoses that affect the locomotor system; that is, muscles, bones, joints and associated tissues such as tendons and ligaments, as listed in the International Classification of Diseases. They range from those that arise suddenly and are short-lived, such as fractures, sprains and strains, to lifelong conditions associated with ongoing pain and disability.
Musculoskeletal conditions are typically characterised by pain (often persistent) and limitations in mobility, dexterity and functional ability, reducing people’s ability to work and participate in social roles with associated impacts on mental wellbeing, and at a broader level impacts on the prosperity of communities. The most common and disabling musculoskeletal conditions are osteoarthritis, back and neck pain, fractures associated with bone fragility, injuries and systemic inflammatory conditions such as rheumatoid arthritis.
Musculoskeletal conditions include conditions that affect:
joints, such as osteoarthritis, rheumatoid arthritis, psoriatic arthritis, gout, ankylosing spondylitis;
bones, such as osteoporosis, osteopenia and associated fragility fractures, traumatic fractures;
muscles, such as sarcopenia;
the spine, such as back and neck pain;
multiple body areas or systems, such as regional and widespread pain disorders and inflammatory diseases such as connective tissue diseases and vasculitis that have musculoskeletal manifestations, for example systemic lupus erythematosus.
Musculoskeletal conditions are prevalent across the life-course and most commonly affect people from adolescence through to older age. The prevalence and impact of musculoskeletal conditions is predicted to rise as the global population ages and the prevalence of risk factors for noncommunicable diseases increases, particularly in low- and middle-income settings. Musculoskeletal conditions occur commonly with other noncommunicable diseases in multimorbidity health states.
(Text taken from World Health Organization (WHO) website)