Dizziness is an often misunderstood condition that can significantly impact one’s quality of life. For many, it can strike unexpectedly, turning a moment of joy into a challenge. Finding the right specialized treatment is crucial not only to alleviate symptoms but also to identify the underlying causes that may differ from person to person.
In this blog, we will explore the experiences of three individuals—Mary, James, and Peter—who each grapple with dizziness in different ways. Through their stories, we aim to shed light on the complexities of vestibular disorders and emphasize the importance of receiving focused care.
Mary’s Vacation Turned Nightmare
Mary, 26 years old, was looking forward to her long-awaited vacation in Portugal. While enjoying the warm sun and the golden sands of the Algarve, Mary began to feel unwell. She thought perhaps it was from the long flight and jet lag. However, as the day progressed, she began to feel dizzy and nauseous, almost to the point of near vomiting.
The dizziness caused such an imbalance that she had to grip her husband’s hand tightly while walking. The ground felt like it was shifting and tilting. Then suddenly, she began to lose hearing in her left ear. Her husband called emergency services, and Mary was taken to a nearby hospital.
While there, the doctors examined her. An MRI of her brain was done, and the results were normal. She was admitted overnight, and by the next day, a dizziness specialist examined her and diagnosed her with labyrinthitis, an infection of the vestibular nerve that supplies the vestibular labyrinths in her left ear.
Immediately, the doctor injected her ear with a steroid medication to reduce the inflammation. Over the next few days, Mary’s dizziness improved from severe to mild. However, she still felt off balance. The ground still seemed to tilt sideways, and each time she turned her head, she would feel dizziness and nausea. By now, she had lost all hearing in her left ear.
James’s Experience with Dizziness
James is a 47-year-old gentleman who is very active in the sport of triathlons. One evening after an hour of swimming and an hour of running, he felt satisfied about his day’s training towards the Kona Triathlon. While sound asleep at around 2:30 AM, James was awakened by a severe feeling of the room spinning.
The dizziness was so severe that he barely made it to the bathroom to vomit. The sensation lasted well into the early morning. Fearful that he might have experienced a stroke, James called 911, and the ambulance took him to the hospital emergency department. While there, the doctors diagnosed him with benign vertigo and discharged him home the same day.
Peter’s Ongoing Struggles
Peter is a 79-year-old retired engineer. About a year ago, he was hit by a car while crossing the street. Since then, he has experienced episodic dizziness, lasting about 1-2 days. Doctors have examined him without any clear findings or diagnosis to explain his symptoms. Recently, Peter noticed his dizziness began to worsen.
Instead of a feeling of lightheadedness, he felt the world was bobbing up and down each time he turned his head. He felt so imbalanced that he needed walking poles for support. He fell twice recently when he tried to walk while turning his head. To avoid falling, he had to walk with his feet spread apart and look down at the ground about 5 feet in front of him. If he turned his head while moving, he would lose his balance and fall.
Common Threads: Dizziness
What do Mary, James, and Peter all have in common? Dizziness. When people think of physiotherapy, they do not often think about our role in treating dizziness disorders. The management and treatment of these conditions are not traditionally taught in physiotherapy schools but are a postgraduate specialty in physiotherapy practice known as Vestibular Rehabilitation.
Understanding the Vestibular System
The vestibular system helps us know where we are in space, with the vestibular labyrinths in our inner ear being the most responsible organ. Specialized nerves from this organ make vast and complex connections to every part of our brain. This system works with the visual system (our eyes), the musculoskeletal system in our neck, and our entire body to coordinate movement.
Along with our eyes, ears, and muscles, the vestibular system helps us walk, run, jump, spin, turn, and perform somersaults with incredible precision. We can purposely provoke this system into feelings of dizziness by spinning around quickly in circles or going on amusement park rides. The giggles and laughter that dizziness brings are comical, but only because it is short-lived. Imagine having to live with your world moving and spinning, losing your balance without choosing to do so. Life would be miserable.
Treatment for Mary: Labyrinthitis
Mary’s diagnosis of labyrinthitis is an infection of the inner ear that produces dizziness and hearing loss. Sometimes, the hearing loss can recover, but at other times, it can be permanent. Oral steroids are usually tried first; however, steroid injections into the ear itself may also be attempted to prevent hearing loss.
Vestibular Rehabilitation for Labyrinthitis
The labyrinthitis causes a reduction in the function of the vestibular apparatus in the affected ear. Exercises are prescribed to recover the function of this organ to resolve the dizziness. Most of the time, the visual system is affected due to its close relationship with the vestibular labyrinths. The condition results in reduced eye movements, especially when turning the head toward the affected ear. The eyes also struggle to maintain fixation on objects during head movements, leading to dizziness and blurred vision.
Physiotherapy treatments involve gradually increasing eye and head movements while the person tries to maintain a fixed and clear gaze on an object. Eventually, with time and training, coordination between the ears, eyes, and head improves, leading to the resolution of the person’s dizziness.
James’ Diagnosis: Benign Paroxysmal Positional Vertigo (BPPV)
For James, he sustained a condition called Benign Paroxysmal Positional Vertigo (BPPV). In this condition, microscopic crystals in the vestibular labyrinths of the inner ear can become dislodged and enter one or several of the semicircular canals. As the fluid in these canals moves with head movement, the dislodged crystals change the flow of the fluid, leading to severe spinning dizziness known as vertigo.
How Physiotherapy Helps BPPV
An accurate diagnosis is key in treating BPPV. A physiotherapist will first take a careful and thorough history, as BPPV tends to behave in specific ways. If the patient does not present with any concerning symptoms, several bedside tests can be performed to confirm the diagnosis and determine which ear and canal is affected.
Once identified, the dislodged crystals can be repositioned back to their original location by performing Canal Repositioning maneuvers on the treatment bed. Very specific maneuvers are designed for specific canals. The more accurate the diagnosis, the more effective the chosen maneuvers will be. Once the crystals have returned to their original location, the patient’s symptoms are typically resolved.
Peter’s Complex Case
The situation with Peter was more complicated. I assessed Peter thoroughly by asking many questions about his symptoms and how they were behaving. I then performed a cranial nerve examination, testing the functions of these nerves located in the midbrain.
Using specialized infrared goggles that block out ambient light, I examined his eyes, assessing pupil dilation/constriction and eye movements, especially with head movements. I proceeded to assess his walking gait pattern and carried out a series of cognitive tests involving immediate memory and concentration.
Peter demonstrated concerning eye movements, an ataxic gait (stiff-legged, legs spread apart, and nearly falling forward), as well as some slurring of his speech and weakness in both his upper and lower extremities. Emergency services were called, and while at the hospital, Peter was eventually diagnosed with a cerebellar stroke.
The Importance of Accurate Diagnosis
My most important role as a Vestibular Physiotherapist is to ensure patients are correctly diagnosed and managed. Benign central disorders, like migraines and anxiety, can also cause dizziness. However, in Peter’s case, the central signs were concerning and could indicate a stroke.
My Journey into Vestibular Rehabilitation
My journey into Vestibular Rehabilitation began in 2009, about 13 years after graduation. I recall seeing many dizzy patients, and without formal training in this field, I often had to refer these patients to their family doctors. Unfortunately, many doctors at that time were also not prepared or trained to assess and treat these conditions.
As a result, many patients would be referred to the emergency department, where expensive imaging was ordered for many simple and benign conditions. This was not an efficient use of healthcare resources, leading to delays in proper management and creating a lot of anxiety and uncertainty for patients.
Back then, there were very few courses that trained physiotherapists in this area. Fortunately, this began to change, and formal training to achieve an Advanced Vestibular Rehabilitation Certification became available. Currently, only two universities in the world offer this certification: Emory University in Atlanta and the University of Pittsburgh in Pennsylvania.
Achieving Advanced Certification
I am pleased to announce that I successfully completed the Advanced Vestibular Rehabilitation Certification through the University of Pittsburgh as of April 2025. This certification now gives me the confidence to manage highly complex vestibular conditions and concussion injuries.
The certification process was difficult but immensely rewarding. It marked the culmination of 16 years of vestibular practice for me. Combined with my 29 years of overall practice, this new training in the field of neuroscience allows me to manage vestibular and concussion conditions with greater skill, knowledge, and confidence.
Have you or someone you know been experiencing episodes of dizziness? At Elevation Physiotherapy, we are dedicated to providing comprehensive evaluations and tailored treatment plans for individuals dealing with vestibular disorders. Don’t let dizziness disrupt your life, reach out to us today to schedule a consultation and take the first step toward regaining balance and improving your well-being.