Not long ago, a man in his mid-80s came to the Physical, Occupational and Speech Therapy Outpatient Clinic at Sentara Martha Jefferson Hospital complaining of dizziness. He walked slowly, hesitantly.
“Normally, he was a pretty functional, strong guy,” says Anne Knox, PT, MSPT, GCS, a physical therapist who specializes in vestibular and balance disorders. “He would help his church with building projects and did a lot of woodworking and yard work. But then he had a sudden onset of vertigo, with nausea and other problems.”
After checking him over, Knox diagnosed the man with benign paroxysmal positional vertigo (BPPV), one of the most common types of vertigo.
Those who suffer from vertigo experience a spinning sensation and feel as if their visual field is moving. The condition also may come with lightheadedness, dizziness, nausea and a loss of balance. Episodes are brought on by changes in head position, such as bending over, looking up or down, and turning the head quickly in any direction. Fortunately, once diagnosed, BPPV and most other forms of vertigo are highly treatable.
Most inner ear disorders are grouped together under the general category of dizziness by those who are not trained in vestibular therapy. As such, they often go undiagnosed.
“What’s interesting about vertigo is that, although it’s so common, it’s poorly understood by healthcare practitioners,” Knox says.
A Problem of the Inner Ear
BPPV is a disorder of the body’s vestibular system, which is part of the inner ear.
“The vestibular system is responsible for our sense of hearing, and for providing our brain with information about motion, head position and space,” says Jeb Brittle, MPT, a physical therapist at Sentara RMH. This information allows us to keep our balance, stabilize our head and body during movement, and maintain posture.
“When you have trouble with your vestibular system, you can have difficulty with balance, dizziness and walking,” Brittle says.
The two main causes of vertigo that Knox and Brittle see in their clinics are BPPV and vestibular neuritis, which is an inflammation in the inner ear.
BPPV occurs when debris has collected within a part of the inner ear. This debris, formally known as otoconia and sometimes referred to as “ear rocks,” is made up of small crystals of calcium carbonate. With head movement, the displaced otoconia shift, sending false signals to the brain and causing the eyes to move in a specific pattern known as nystagmus. This eye twitching makes it seem like the room is spinning, Knox explains.
In addition to dizziness, symptoms of BPPV include lightheadedness, nausea, vomiting and blurred vision. Episodes of BPPV symptoms tend to last about 10-60 seconds.
Vestibular neuritis can be caused by an infection or inflammation in the inner ear, says Brittle. Its symptoms can be mild or severe, ranging from subtle dizziness to a violent spinning sensation (vertigo), as well as nausea, vomiting, unsteadiness and imbalance, difficulty with vision, impaired concentration, and severe disorientation.
Symptoms of vestibular neuritis usually come on suddenly, with severe dizziness starting abruptly during routine daily activities. In some people, the symptoms are present upon awakening in the morning. This sudden onset can be frightening.
“The symptoms can last for two to three days,” Brittle says. “They may be so severe that they affect a person’s ability to stand up or walk.”
When patients come for physical therapy for vestibular disorders, they’re often stressed—not only by their condition, but by the effort it often takes to get the condition diagnosed and treated.
“Physical therapy is really highly effective at treating vertigo, with 80-90% success,” says Brittle.
During treatment for BPPV and vestibular neuritis, a physical therapist guides the patient through certain exercises. The most common therapy for BPPV is known as the Epley maneuver.
“With that maneuver, we’re trying to get those crystals back into the part of the ear where they belong,” Brittle says. “Typically, in just one or two visits, patients with vertigo are cured.”
When physical therapists can’t figure out where a patient’s symptoms are coming from, they still can try to find ways to help them adapt.
“We look at the big picture,” Knox says. “We can make recommendations that will make the person’s life better. They really appreciate that.”
As for medications, the most common one prescribed for dizziness is meclizine. However, explains Knox, meclizine actually suppresses the vestibular system, when the ideal solution is to get the system to work better.
“In the acute phase of vertigo, meclizine can help,” says Knox. “But when you’re trying to recover, you want the vestibular system working.”
Who Gets Vertigo and Why
Dizziness is the second-most common complaint heard in doctors’offices, according to the National Institutes of Health.
For individuals over age 70, dizziness is actually the No. 1 medical complaint. Although very common, acute or chronic problems with equilibrium can limit a person’s everyday living. So it’s crucial for elderly persons with a vestibular balance disorder to be treated, says Brittle.
“When the elderly lose their sense of balance, they often become scared they will fall and break a hip—so instead, they just sit,” he adds. “And when they do get up, they go real slow, take a step and stop.”
That lack of movement can cause older individuals to deteriorate and lose muscle strength, which in turn further contributes to their lack of balance.
“It’s kind of a snowball effect for the elderly,” Brittle says. “Generally, if someone in their 30s or 40s gets vertigo, they make the best of it and get back to work because they can’t afford to be off. They really just retrain themselves to adjust to a new sense of balance.”
Knox notes that treating older people can sometimes be multilayered. Her patient mentioned above—the man in his mid-80s with BPPV—also had arthritis in his neck, so he wasn’t able to do the therapy exercise Knox prescribed. To work around that problem, she used a special table that moved the man’s whole body to accomplish the maneuver.
Although the BPPV quickly cleared up, the man still had a balance problem.
“COVID restrictions had made him less fit,” she says. “His quality of life had changed.”
So Knox worked with him on his gait.
“Gait speed is very important,” says Knox. “Faster walking is correlated with good health.”
In addition, the man had cervicogenic dizziness—another type of vertigo—so he got dizzy whenever he looked up. Knox advised him to stay off ladders. The patient was more than happy with his therapy, which had restored his quality of life.
“By the time he left,” Knox says, “he was feeling like Superman.”
Need physical therapy to treat vertigo? Talk to your doctor (a referral is needed), then call:
In Charlottesville: 434-654-8333
In Harrisonburg: 540-689-4999