I think we can all agree that there have been lots of strange happenings during this last year—coronavirus and Brexit have been the most prominent by far, but another thing I’ve noticed is how many people have suffered with dizziness.
They tend to be people who have been isolating and haven’t knowingly had coronavirus, and so I’ve been wondering about its cause. I’d been intending to research the subject for some time, but then my hand was forced when a family member became pretty disabled with the condition. This person, who we’ll call Grace, is eighty-six. She’s become rather frail during lockdown, and this dizziness, which she’s had since last November, is really debilitating. The NHS has done its best. She’s had her heart checked, and there is nothing of concern. Now, she has an appointment with an ENT specialist, but the appointment date is June 2022—yes, 2022. Grace weighs around six stone, and she’s osteoporotic. Every time she gets up, she sways from side to side—she is a fall waiting to happen. She is incapacitated by her dizziness and no longer goes out on her own. There are no trips on the bus or walks down the high street. She uses a stick in one hand and holds on to her husband with the other. She has lost all her independence, and she is losing her strength and agility too. She can’t wait a year for a resolution. She needs to move, and I felt that with a bit more knowledge I might be able to help her. So, with that in mind, I booked myself on a dizziness course with a fabulous physiotherapist called Alan Sealy, and this is what I discovered.
What is dizziness?
Dizziness is extremely common, with around 5% of the population suffering from it at any one time. 80% of these people limit their daily activities, and it can be highly debilitating. The chances of dizziness increase with age, and it is one of the most common reasons for visiting a GP. Whilst it is poorly researched, the studies that exist suggest confusion around the subject, leading to treatment being haphazard and sometimes ineffective. Often an acute attack of dizziness becomes a long-term problem because it is untreated.
Dizziness can mean many things:
... all are balance disorders.
To balance, we use sensory information from our musculoskeletal system, our eyes and our inner ear. These three systems work in unison to help us balance.
Sensors in our joints, muscles and skin give us proprioception. This is how we know where we are in space. For example, when we stand on one leg with a hand behind our back and our head slightly turned to the right, it is the feedback from our proprioceptive sensors which informs us that we are in this position. They send messages to our brain, which interprets these messages and sends commands back to our muscles and joints to react. Our proprioception is probably our most crucial balance system. As we age, we move less and so our proprioception is tested less, which means we become less proprioceptively fit (I might have made up that phrase). In Pilates, we use balance pads and balls, equipment like the reformer, tiptoes and one-legged standing to test our proprioception.
Our eyes are another balance organ. They are our gateway to the outside world. They are probably our least important balance organ—after all, a blind person can balance quite successfully—but as we age, we tend to depend on this part of our balance system more. You will know this yourself if you test it. Stand on one leg and notice how long you can maintain your balance. Now stand on one leg and close your eyes. I bet that you will feel incredibly unsteady pretty quickly. I have read several articles stating that we can no longer balance on one leg with our eyes closed after fifty. I would debate this fact. In my view, we can no longer balance with our eyes closed because we never do it. In my classes, I train the balance system by disturbing vision. We move our eyes and our head so that we can’t fix our gaze. We close our eyes in positions that are safe but make us slightly unsteady.
Our final balance sensory organ is in our inner ear, and it’s known as our vestibular system. Whereas our proprioceptive system is primary when it comes to balance, a problem in our vestibular system is the most usual reason for sudden onset vertigo or spinning. Simply put, our vestibular system is a motion detector. It’s made up of three semi-circular canals that sit at right angles and a central part called the otolith. The otolith responds to gravity and acceleration, and the semi-circular canals react to movement. Because the canals are at right angles to each other, at least one will be stimulated whatever our direction of motion.
So, to balance, our brain takes sensory information from these three systems. It organises and integrates this information with our memory, beliefs, expectations and emotions, and it tells our muscles and joints how to react. If there is a mismatch of information, then dizziness or unsteadiness may occur.
Imagine sitting on a stationary train, looking out at another train as it begins to move. Your eyes see movement, but your inner ear and musculoskeletal system aren’t stimulated. This mismatch of information would probably cause you to feel unsteady. On a roundabout, as you spin, you may feel dizzy, but this is nothing compared to the feeling when you jump off. Suddenly your eyes and musculoskeletal system inform your brain that you are still, but the fluid in your inner ear is still whirling around and you have vertigo to such a degree that you may fall over. When we are children, we find these experiences fun and seek them out, but as we grow older, they become unpleasant, and many of us find them terrifying. Unfortunately, fear of dizziness can cause an acute problem to become chronic. An experience of dizziness on a bus may be very scary, and the next time we use the bus, we battle with our memory and emotions. There is no longer a physical problem—the inner ear infection has cleared, but our heightened responses to the fear we feel cause us to feel unsteady again. This reinforces our beliefs and may even stop us from using a bus again. Experiences of dizziness can sometimes lead to repeat experiences which can be very disabling.
Types of dizziness
The reasons for dizziness are varied. Whilst some are serious, others are simply a matter of seeing stars because you haven’t eaten for a while and have low blood sugar.
Let’s get the serious stuff over and done with before moving on to the more common causes of dizziness. Sudden onset dizziness can be an early sign of a stroke. In this case, other new signs such as slurred speech, double vision, swallowing difficulties and walking or coordination problems accompany it. If you suddenly get dizzy and have some other new symptoms, you should ring 111 immediately to get advice.
The most common cause of sudden onset dizziness is benign paroxysmal positional vertigo (BPPV). You will know if you have this because it occurs with specific movements and lasts for up to a minute. It happens because fragments from the otolith escape into one of the fluid-filled semi-circular canals. Specific actions excite these fragments and cause them to move around the canal. For example, consider a snow globe scene—maybe there is a cottage in the forest with snow covering the ground. As you pick up the globe, the fluid inside it moves, disturbing the snow and causing a snowstorm. Within a minute, the storm subsides, and the calm forest scene is restored. What happens with otolith fragments which have made their way into the semi-circular canal is very similar. The dizziness occurs because of the mismatch of information between the left and right inner ear and other balance organs.
With BPPV, the bad news is that vertigo will occur every time you make the movement that irritates the fragments. Commonly this will be a turn of the head to the left or right whilst getting up or lying down. The good news is that it is reversible with the help of a specialist trained in moving these fragments. You can search the internet for Epley Manoeuvre, and you will find some exercises that may help, but if not, then it’s worth seeking the help of someone like me. We have six semi-circular canals, and treatment is slightly different depending on which canal contains the fragments.
Other causes of vertigo include Meniere’s disease and migraine. Both come in clusters that last a few hours and can be genuinely unpleasant. The difference is that Meniere’s affects the entire inner ear and comes with a low-frequency hearing loss. As a result, sufferers often complain of ringing or fullness in the ear. Migraine does not affect hearing, and it is more common than Meniere’s. As they tend to come in clusters, so you should see your GP after the first attack. Migraine should be treated by avoiding triggers and by using migraine medication. If you have Meniere’s, then your GP will probably refer you to an ENT specialist. Diuretics such as salt, sugar, caffeine and alcohol can trigger a Meniere’s attack, so any sufferer may have to take a vow of abstinence.
If your vertigo attack lasts longer than eight hours, it is most likely labyrinthitis or vestibular neuronitis. Labyrinthitis is caused by an inner ear infection, and can result in hearing loss or ringing in the ear, as well as vertigo and possible vomiting. Vestibular neuronitis is an inflammation of the vestibular nerve and tends not to cause a hearing problem. The GP will help you with these conditions, but early intervention with corticosteroids is important for vestibular neuronitis, so don’t wait too long before visiting her.
Chronic Continuous Dizziness
There is no doubt that chronic dizziness can be a sign of health problems that require the help of your GP but for many, chronic continuous dizziness occurs because a person never fully recovers from a bout of BPPV, Meniere’s or labyrinthitis. The sheer terror of being dizzy on the initial occasion stops the person from moving, which leads to a hypersensitivity to motion, positions and environments. If we don’t stimulate our balance organs, they cannot recover. Grace told me, ‘I don’t turn onto my left side in bed anymore. It makes me feel dizzy.’ Of course, this is precisely what she needs to do.
Vestibular Rehabilitation Therapy (VRT) is an exercise therapy used to treat chronic dizziness. It’s been around since the 1940s, but the exercises have evolved since then. When a person develops a problem in their vestibular system, they will compensate using their vision or proprioception. This means that their vestibular system no longer has to work so hard. Generally, this compensation works well, but as we age, our vision and proprioception start to deteriorate, and this is when dizziness can become an issue. The main aim of VRT is to use habitation exercises to gently increase exposure to the movements that provoke dizziness. We use head and eye movements in lots of different environments and as we progress, the very tasks that cause the dizziness are utilised as exercises. Advanced training might include one-legged standing, a balance pad and closed eyes. VRT can take anywhere from two weeks to six months to complete, but it has to be worth it when the alternative is limiting your activities.
In the Pilates studio, we do balance training in most of our over-50s classes. These are pretty similar to the exercises used in VRT, except they are not individualised. Not only are these types of exercises vital for conditions such as Parkinson’s, MS and ataxia, but they are helpful to anyone ageing—they prevent falls and stimulate a balance system that gets a little lazy if not used. Most classes involve at least twenty minutes of standing work, going onto tiptoes, one leg, twisting and turning. We have balls for all types of balancing acts and pads and planks of wood for walking along. You may have taken part in a class where you catch and throw a ball or stand with your eyes closed. It’s all part of our healthy ageing plan.
So, let’s now return to Grace. The cardiologist had checked her heart, so I felt happy to treat her when she visited me a week ago. I could see that her dizziness was positional. When she got up and turned to the left, she rocked around on her feet for twenty seconds before it settled. Her coordination, walking, speech and eye movements were normal, and so I determined this was a case of BPPV in her left vestibular system. I used a version of the Epley Manoeuvre to try to remove the fragments from her canal. On the first attempt, she felt dizzy when I moved her to the first position. It lasted for about ten seconds and then I moved her to the second position. Again, she felt dizzy for a short time. When I moved her to the third position, she felt fine, and she had no dizziness when I moved her to a sitting position. We did the manoeuvre again just to make sure we’d made a positive change. This time she felt no dizziness at all throughout the procedure, and when she stood up, she was far more solid on her feet. Grace had been suffering with this condition for almost a year and after just a few minutes of treatment it had vastly improved. Now it was important to plan some rehabilitation exercises to ensure she made a full recovery. The exercises included standing at her window and following the cars and buses that drive from right to left, using her head and eyes. I also encouraged her to lie on her left side in bed. It has now been a week since the treatment. She has no dizziness, and she is steadier on her feet. I hope she is well on her way to recovery. While she was staying with me, she was far more active than she had been for the last year. She walked up and down the stairs, in and out of the garden. We walked in Bath, and we visited my mum—she’d done nothing like this since the start of lockdown. I’m sure this was a simple case of BPPV, exacerbated by the isolation of the last eighteen months.
Alan Sealy told me he believes young people often suffer from vestibular dysfunctions, but they don’t last because their active lifestyle means that they rehabilitate themselves. Grace, who is highly sociable, used to potter around her local area on a daily basis, but through lockdown she became isolated and starved of stimulus. I wonder how many of us have had our balance system affected by a lack of stimulation. I can’t wait for life to return to normal so that I can test mine by getting out into busy situations where there is plenty of noise and lots of visual stimuli. Travelling on trains and buses, walking to town amongst shoppers, teenagers and buskers, and dancing and drinking with friends at parties all play a vital part in the health of our vestibular system.