When it comes to dizziness, the healthcare system can be difficult to navigate. It's hard to know who to seek care from, in order to get the right diagnosis and treatment. Furthermore, the English language often fails us when it comes to describing dizziness, which can make it hard to communicate with doctors. The fact is that the word "dizzy", can mean a lot of different things.
A person might say they feel:
like the room is spinning
lightheaded
like they're seasick on a boat
motion sick from reading in the car
like they're tipsy/drunk
as if they're falling in a certain direction
like they're seeing double.
like their vision tunnels/goes dark
All of those sensations can be described as "dizzy". The problem is that they don't all suggest the same kind of problem is causing a person's dizziness. Room spinning dizziness is more commonly associated with vestibular problems, often called "vertigo". Lightheadedness, on the other hand, might suggest a circulatory problem where the brain isn't getting enough blood flow. Debunking dizzy and getting to the heart of the problem is important.
To demystify the dizziness that can get in the way of life, we have to sort through:
While it is tempting to jump right to treatment, in order to prescribe a treatment that works, we have to address the root cause of the symptoms. To do that, we have to understand why a person gets dizzy in the first place.
What does it take for the body to be well balanced?
In order for us to feel well balanced, essentially the brain needs three things to add up. The equation balances if the information the eyes send to the brain, matches the information that the vestibular system in the inner ear sends the brain, and they both match the information all the position sensing nerves in the body (called proprioceptors) send the brain. Lastly, the brain has to be able to function to put all the information together. This presents a bit of a problem for getting an accurate diagnosis because most healthcare providers don't specialize in all of those things.
Who should I see for my dizziness?
When a person is feeling dizzy, they can seek care in different places.
ENTs (Ear, Nose, & Throat doctors, also called Otolaryngologists)
Primary care doctors by nature are expected to know a little bit about a lot of things. Their job is to treat common conditions, and to know which specialists to direct you to for care. The typical tools they use to address dizziness are medications that help to reduce nausea and dampen the nervous system's sensitivity to make you more comfortable.
Emergency rooms are set up to evaluate and treat certain kinds of dizziness. They are used to seeing people who have dizziness related to brain injuries, like strokes and concussions. When it comes to the vestibular system, however, their training is limited. They may sometimes diagnose Benign Paroxysmal Positional Vertigo (BPPV), which is the most common vestibular system disorder. The nature of an ER, however, is not to provide long term care. They stabilize patients, and then refer them to other specialists.
Eye doctors primarily focus on dizziness related to visual acuity problems. They can adjust prescriptions of glasses and contacts to help your visual system function better. An eye doctor may also screen your cranial nerves to see if your brain is involved, but they get very little training in the proprioceptive nerves in your body that sense position, and the finer points of the vestibular system.
Otolaryngologists, more commonly referred to as Ear, Nose, and Throat doctors, or ENTs for short, have more experience in the vestibular system. As the nickname suggests, the ear is part of their specialty. They are also acquainted with screening cranial nerves to check if the brain is partly to blame for your symptoms.
Speaking of the brain, the neurologists are the experts there. If damage to the brain is preventing it from putting all the information together that your ears, eyes, and proprioceptive nerves are sending, the neurologist looks for causes and solutions.
The last person you might think of on your dizziness team is your physical therapist. In reality, however, primary care doctors, ENTs, neurologists, and ER doctors all write referrals to PTs to evaluate patients for dizziness. Physical therapists are the movement experts. Neurological problems, vestibular issues, and balance training are all part of their standard education. While you may think of physical therapists as working on muscles and exercise, this actually allows them to provide a unique perspective on visual aspects of dizziness because they are experts in the way the eye muscles work to move the eye.
What causes each type of dizziness?
Now that we've covered who evaluates and treats dizziness, as well as what needs to happen to prevent it, let's talk about why people get dizzy.
2.) Visual Dizziness
Vestibular Dizziness
Most commonly, people refer to their dizziness as "vertigo". True vertigo is a disorder in the vestibular system. The classic complaints of people experiencing vestibular dizziness are that it comes on when they go to lay down or are rolling over in bed. They will complain that the room starts spinning as though they are on a playground ride that they can't get off.
The primary cause of this type of dizziness is movement of the crystals in the inner ear, called otoliths or otoconia. Our bodies use the movement of these tiny calcium crystals to sense the position of our head and body as they shift in the fluid in the labyrinth in the inner ear. Like the name suggests, the labyrinth is a bit like a maze with several complex twists and turns. There are many different problems that can occur in the vestibular system.
Visual Dizziness
When the visual system is causing dizziness, several factors can be at play. The first major factor is visual acuity; how clearly your eyes can see objects. This is what the eye doctor tests when they are determining if you need prescription corrective lenses.
The second major factor is eye movements. We are able to look different directions without moving our heads. That means that the eye itself moves to direct our pupils where to look. In order to take in information effectively, your eyes have to be able to track an object as it moves. This might mean smoothly tracking an object like an airplane as it moves across the sky, or the doctor asking you to follow their finger back and forth. It can also mean the ability of your eye muscles to accurately jump between two objects. For example, when reading this article, your eyes repeatedly jump from the last word in one line of text, back over to the first word in the next line of text as you work your way down the page. These muscles can have coordination problems just like any other muscle. This can lead to the eyes having difficulty supplying the correct visual balance information to our brains.
Third is eye stabilization. It is just as important to be able to move your eyes to the desired location, as it is to be able to hold them still. When you are watching a movie, you want to keep your eyes focused on the TV, not bouncing around between the TV, the floor and the ceiling. Your eyes have to be able to stabilize your gaze on things both when you are sitting still watching TV, and when you are moving. When driving for example, the eyes have to be able to stabilize on a traffic light up ahead even if the car is moving towards the light and simultaneously moving sideways while changing lanes. This forces multiple systems to work together. (Coming soon: Why Driving Makes You Dizzy)
When the visual system and the vestibular system have to coordinate with one another, it gets even trickier. In order for you to fix your gaze on an object while you are moving your head, your brain has to be able to perceive the speed and direction that you are moving your head, and then adjust the direction your eye muscles pull your eyeball in a fraction of a second.
Keep in mind this isn't an exhaustive list. There are other less common visual factors like problems with pupil dilation, eye dryness, traumatic eye injuries, and strabismus that can contribute to dizziness.
Proprioceptive Dizziness
When the proprioceptive system is causing problems, the nerves are to blame. Proprioceptors are nerves that sense position in our bodies. If the proprioceptive nerves are not sending the right messages, we often think of people with this problem as being "clumsy". This can be related to genetic predispositions, as well as lifestyle and environmental factors.
Some people like those with connective tissue disorders like Ehlers Danlos that affect the ligaments can also struggle with proprioception. While these nerves are spread throughout the body, many of them are concentrated in the ligaments near your joints. The ligaments are a strategic location to house these nerves because they support the joints, which serve as the pivot points where our bodies change position.
For people who are born with a typical, healthy proprioceptive nervous system, it still needs to be trained. Children are all clumsy when first learning to walk. As we use our bodies throughout our lifetimes, they become more skilled at the activities we practice. A concert pianist may have incredible coordination and dexterity in their hands and be able to play Mozart blindfolded. That same pianist, however, may not have the position sense in their feet to walk across a balance beam with their eyes closed.
The proprioceptive nerves can become damaged in a variety of ways including:
Chemical agents like chemotherapy medications or environmental toxins.
Long term exposure to poorly controlled blood sugar levels
Chronically poor circulation/blood flow which limits oxygen/nutrient supply
Traumatic injuries like ligament tears or surgeries.
Conditions/habits associated with these types of problems might include neuropathy, diabetes, smoking, peripheral vascular disease, and traumatic injuries.
Central/Brain Dizziness
Assuming that the eyes, the vestibular system, and the proprioceptive nerves are functioning correctly, the final hurdle to cross is in the brain. Your brain has to be able to synthesize all of this information correctly. While the nerves from the eyes and the vestibular system connect to the brain directly, it bears mentioning that proprioceptive nerves have to communicate with the spinal cord first on their way up to the brain. Nerve root problems in the spine and injuries to the spinal cord can cause sensory processing problems on their own.
Once the information gets to the brain, it has to be able to put it all together. This means that the brain has to have what it needs to function. Some people describe their dizziness as feeling "lightheaded" which can be a sign that the brain isn't quite getting what it needs. Circulatory conditions like dysautonomia (the most commonly diagnosed form being POTS) can cause periods of slightly decreased blood flow to the brain which can cause a person to feel lightheaded. If the loss of blood flow is significant enough, the person may experience tunnel vision and "black out", or faint.
The brain structures also have to be connected and communicating well. Some dizziness is caused by damage to the brain, such as from a stroke or a concussion. There are also many neurological disorders that can affect the brain such as Multiple Sclerosis (MS), or Parkinson's disease.
What can I do to treat dizziness?
Vestibular Dizziness
In terms of short-term symptom management, if the vestibular system is to blame for your dizziness, closing your eyes often makes the problem worse. People whose vestibular system is sending the wrong information often feel most comfortable when the other systems are still sending the right information to the brain. They will commonly prefer to fix their eyes on something to try and stabilize their gaze. They also tend to prefer having a lot of touch contact. They might spread their arms out and press them into the bed to maximize the amount of tactile contact they have so that the proprioceptive nerves can send signals to the brain saying that the body is stable.
The most common problem diagnosed in this area is called BPPV, or benign paroxysmal positional vertigo. Some patients are diagnosed and sent home to do what's called an Epley Maneuver to self-treat the problem. It is a series of movements that aims to move the crystals through the labyrinth back into the right position. It doesn't work for everyone, however, because it assumes the crystals are in the most common position. If an Epley maneuver isn't working for you, it's best to consult a vestibular physical therapist for further evaluation to make sure you are treating the right problem. They can also help you to perform the maneuver correctly, as some people struggle to get in the right positions for the multiple step maneuver. It's also common that when performing an Epley maneuver at home, patients don't hold the positions long enough to obtain benefit. Consulting a vestibular physical therapist can help you trouble shoot why the maneuver isn't working for you.
Visual Dizziness
As a general tip for symptom management, if the visual system is giving the brain incorrect information, closing your eyes usually helps to reduce the symptoms, at least temporarily. If you find your dizziness is better with your eyes closed, it's a good indicator that the visual system is contributing to the problem.
If the visual acuity in the eyes isn't adequate, you might need corrective lenses in order to see things that are near or far away. If you aren't sure and want to test yourself before making a trip to the eye doctor, you can screen yourself at home. Eye charts can be printed off from online in the standard sizes used at the eye doctor's office. You can then stand the designated distance away and try to read the chart with each eye. It isn't as precise as going to the eye doctor, but it can give you a rough idea of your visual acuity.
For dizziness that stems from an eye movement problem, a physical therapist can teach you eye exercises to train your eyes to move more effectively. There are multiple eye exercises depending on the types of movements that your eyes are struggling to perform correctly. Working on these exercises and gradually increasing their difficulty level will often resolve these issues.
Proprioceptive Dizziness
As with the other forms of dizziness, increasing the level of correct input your brain receives is helpful. Keeping your eyes open to ensure good visual feedback often improves your sense of balance if the proprioceptors aren't functioning well.
While current medical understanding cannot reverse all types of nerve damage (i.e. from some chemotherapies), some types of proprioceptive problems are treatable. If some sensory nerves are still working, those nerves can be trained to be more efficient. Balance exercises that emphasize controlled/intentional movement can improve coordination and balance. This often means slowing down while performing the exercise to give the nerves more time to sense what you are doing. This type of training can also be helpful for people with connective tissue disorders, like Ehlers Danlos. They can also help people who are just generally a little "clumsy" from lack of practice training their nervous system.
Your therapist may ask you to perform very specific movements to improve your balance and the posture/technique matters. Many people with proprioceptive limitations struggle to know if they are performing an exercise correctly or not. This may mean they need help from an outside observer like a physical therapist to coach them through performing the movements correctly.
It can also be helpful to work on balance exercises while receiving input from the other systems. Your physical therapist may encourage you to perform balance exercises in front of a mirror in order to help your nerves orient themselves to where your body is in space with the visual feedback from your eyes.
Central/Brain Dizziness
When it comes to treating the central nervous system, the best treatment is very dependent on the type of disorder causing the problem. Neurologists are often the most skilled provider to help with medication management for disorders like Multiple Sclerosis and Parkinson's Disease.
Strokes and concussions that have caused some degree of damage to the brain tissue are typically treated with structured exercise protocols by physical therapists, occupational therapists, speech therapists, and athletic trainers. Because the brain is a highly individual organ, it's important to work with a trained clinician who can tailor the exercise program to the area of the brain that has been damaged.
If a circulatory problem like dysautonomia is to blame, working with a cardiologist to manage medications, and a physical therapist to train the cardiovascular system to better support brain function are the preferred treatments.
In closing, when it comes to dizziness, remember to put safety first. If you're dizzy, you shouldn't drive or operate heavy machinery. You are also at an increased risk of falling when you are walking and moving around. It may be best to have someone there to help you maintain your balance when you are trying to move around and/or use assistive devices.
While this article is intended for educational purposes, it is not a replacement for individual medical advice from a licensed healthcare provider. If you are interested in scheduling an evaluation to have a physical therapist review your unique situation, we encourage you to call or book online to schedule an appointment.
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