Dizziness is a non-specific term used by patients to describe symptoms of impaired spatial perception and imbalance.
Vertigo is a sensation of rotation or movement of one’s self (subjective vertigo) or of one’s surroundings (objective vertigo) in any plane. Vertigo may result from diseases of the inner ear or from disturbance from the vestibular pathways in the central nervous system.
Disequilibrium is a feeling of unsteadiness or imbalance on standing or walking and may be due to visual or proprioceptive abnormalities.
Dizziness can have a multi factorial origin and is commonly associated with the following disorders: vertigo, disequilibrium, pre-syncope, and non-specific dizziness.
- Benign paroxysmal positional vertigo (BPPV)
- Vestibular neuritis
- Meniere’s disease
- Vestibular migraine
- Acoustic neuroma
- Multiple sclerosis
- Cervical arthritis
- Peripheral neuropathy
- Visual impairment
- Vestibular dysfunction
- Neurologic/neuromuscular disease (CVA, Cerebellar disorders, Parkinson’s disease)
- Orthostatic hypotension
- Aortic Stenosis
- Post-prandial hypotension
- Pharmacologic (cardiac, CNS, urologic)
- Metabolic( Diabetes Mellitus, Hypothyroid)
Epidemiology including risk factors and primary prevention
- Precise data on the incidence and prevalence of dizziness is largely unknown1, 2. Overall incidence is estimated between 5-15% US population3 and approaches 40% after the age of 403. Dizziness due to vestibular and psychogenic causes constitutes more than 70% of cases. Serious causes are found in a minority of patients and no cause is found in 7% of cases4.
- Dizziness is the primary complaint in 3% of primary care and emergency department visits in patients 25 years or older5. Acute dizziness is most often caused by benign conditions, such as peripheral vertigo, orthostatic hypotension, and psychogenic disorders, whereas serious neurologic conditions, such as stroke and brain tumors, are rare6. Cardiovascular disease was found to be the most common major cause of dizziness in older adults in primary care. 25% of these patients experience an adverse drug effect causing dizziness 7.
- Otologic disorders account for 30-50% of all identifiable causes of dizziness, followed by syncopal/disequilibrium (25%), psychiatric (15%) and central brainstem vestibular lesions (10%)
- Stroke accounts for 3-7% among all causes of vertigo8.
- The elderly have the highest of central causes of vertigo (20%) and is most often attributable to stroke. The prevalence of dizziness in the older adults (age> 65) ranges from 4-30%. Prevalence increases by 10% for every 5 years of age thereafter.
- Age: > 65 years old are at risk due to an increase in medical conditions and their use of medications.
- Medications: Anti-seizure medications, anti-hypertensives, anti-depressants, barbiturates, cocaine, diuretics, nitroglycerin, quinine, salicylates, ototoxic drugs, sedatives, and tranquilizers can cause dizziness.
- A past episode of dizziness may predispose to recurrence
- History of migraines, CVD/risk, Trauma, Psychosocial stress/depression and exposure to toxins.
- Dependent on the underlying specific cause of dizziness.
- Dizziness is a sensation of postural instability. Cerebral cortex and cerebellum integrate sensory information obtained from the visual, auditory, vestibular and proprioceptive systems to maintain balance and equilibrium thru appropriate motor response 9. Disturbance in any of these areas may result in dizziness. The differential diagnosis of vertigo includes peripheral vestibular causes (i.e., those originating in the peripheral nervous system), central vestibular causes (i.e., those originating in the central nervous system).
- Blood perfusion to the brainstem, cerebellum and inner ear arise from the vertebra-basilar system. Nausea and vomiting with vertigo and nystagmus represent symptoms of stroke in the posterior fossa from arterial occlusion or rupture of the vertebro-basilar system. However, the signs and symptoms as a manifestation of stroke associated with dizziness and vertigo may vary depending on the affected vascular territory. Vertigo is a subtype of dizziness. In the emergency room, central vertigo due to strokes or transient ischemic attacks should be considered in patients presenting with acute dizziness. Due to the overlapping of symptoms, it is hard to differentiate between vascular vertigo and other causes of vertigo . The most common causes of vertigo are benign paroxysmal positional vertigo (BPPV) and Meniere disease; both of them are inner ear disorders, while other causes of vertigo are central vestibular lesions such as cerebrovascular disease and acoustic neuroma. Dizziness may be of cardiovascular origin.
- State of consciousness is maintained by adequate cerebral blood flow. Cardiac syncope results from inadequate effective cardiac output and may be due to serious underlying structural heart disease. Arrhythmias are the most frequent causes of syncope and dizziness. Syncope from arrhythmia results from ventricular tachycardia, which accounts for 11% of all cases of syncope 10. Vasovagal syncope can be caused by acute stress or fear and is also seen in anxiety, panic, and major depressive disorders.
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time):
Depends on the etiology and its progression that is responsible for dizziness.
Acute unilateral injury to peripheral or central vestibular structures present as acute vestibular syndrome consisting of severe vertigo, nausea and vomiting, spontaneous nystagmus, and postural instability11.
Healthy young people usually have a benign and self-limited course with acute vertigo. Persons with risk factors for stroke who do not have the typical findings of spontaneous nystagmus and postural instability should be evaluated promptly for a cerebellar stroke with imaging.
Up to 30% of patients who experience episodic balance problems develop persistent unsteadiness or dizziness. Treatment consists of pharmacotherapy, vestibular and balance rehabilitation therapy (VBRT). VBRT is an excellent habituation/desensitization program for chronic dizziness. In addition, cognitive-behavioral therapy may be helpful for dizziness due to anxiety or depression 12.
About 3% to 5% of American adults have recurrent bouts of dizziness and 1% have complains of persistent dizziness.
Specific Secondary or Associated conditions and complications:
Secondary conditions: Age, migraine, hyperlipidemia hypertension, and stroke were independently associated with BPPV 13.
Complications: Dizziness can interfere with driving, work, and lifestyle. Dizziness is incapacitating and leads to decreased productivity, clinical depression, and falls with injuries including hip fractures.
2. ESSENTIALS OF ASSESSMENT
Interview should be focused on patients’ description of symptoms and/or sensations experienced, and should include time course, provoking and aggravating factors, recent trauma, as well as associated symptoms. Additional history should include prescribed medications, alcohol and caffeine consumption, and recreational drug use.
Common descriptions include by category5:
- Vertigo: sensation of motion, “spinning”, “whirling” or “tilting”.
- Disequilibrium: sensation of “imbalance” or “wobbly”
- Pre-syncope: sensation of “passing out”, “blacking out” or “losing consciousness”
- Non-specific dizziness: vague symptoms of “lightheadedness”, “giddy”, “faint” or “disconnected with environment”.
Initial focus should include a comprehensive neurologic and cardiopulmonary examination, followed by supplemental testing used to provoke patient symptoms. This should include: spontaneous and gaze-evoked nystagmus; bedside vestibulo-ocular reflex assessment; positional testing; and gait and balance testing.
Clinical Functional Assessment: mobility, self-care cognition/behavior/affective state
A thorough history should include how patients’ symptoms impact mobility and ADLs. Additional information should be gathered on previous diagnoses of mood or psychiatric disorders as and present affective state. While no specific functional assessment has been shown to assist in the underlying diagnosis for dizziness, gait and balance testing should be standard for all examinations.
Laboratory studies, including hormone and metabolic panels, are very low yield in diagnosing the cause of dizziness. In one meta-analysis, 0.6% (26 of 4,538) of patients had laboratory abnormalities 5.
Lab work with hemoglobin/hematocrit, Glucose, Electrolytes, BUN, Folic acid Vitamin B12 and Thyrotropin should be performed in all cases with chronic dizziness and Tilt table test for patients with syncope or postural hypotension. For vestibular disorders, electro-nystagmography, rotational testing and dynamic Posturography are helpful. If arrhythmias are suspected, EKG, Holter and event monitoring ECHO and carotid Doppler should be done 9.
Imaging is not beneficial unless an underlying neurologic abnormality is suspected5.
Supplemental assessment tools:
- Dix-Hallpike maneuver, a test for BPPV – involves rapidly moving the patient from a sitting position to “head hanging,” where the patient’s head is at least 10 degrees below horizontal. Onset of vertigo and nystagmus indicating a positive test
- Orthostatic blood pressure
- Romberg test
- Standardized psychological testing
- CV testing: EKG/Holter, ECHO, carotid Dopple
- Vision and Hearing tests
Early prediction of outcomes:
Predictors of outcome are dependent on underlying cause for dizziness. Most causes of dizziness are benign and up 30% resolve spontaneously by two-weeks of symptom onset and up to 50% resolve by one-year 14. The absence of early activity and/or rehabilitation may prolong recovery
Social role and social support system:
For most causes of dizziness, the role of social supports is undetermined. In psychogenic or undetermined etiologies however, social and psychiatric support may have more of a definitive role in recovery.
Diagnosing dizziness is challenging, as it is a non-specific symptom associated with numerous possible underlying etiologies. A careful history and physical examination will usually point to the probable cause. Cardiovascular, neurologic, and laboratory testing should be guided by the clinical evaluation.
There are no established guidelines for when to make specialist referrals, when to do imaging studies, or when to make activity and/or rehabilitation recommendations. Multifactorial interventions will help chronic dizziness and assist in day to day functioning and quality of life.
3. REHAB MANAGEMENT AND TREATMENTS
Available or Current treatment Guidelines
- Medical management of dizziness depends on its cause.15
- Dizziness from medication use responds to withdrawal or dose adjustments of the offending agent.
- Vestibular suppressants; anticholinergics, antihistamines, benzodiazepines, calcium channel antagonists and dopamine receptor antagonists give symptomatic relief of acute dizziness.
- Compression stockings may help with orthostasis
- Rehabilitation program consists of 16, 17
- Investigation and Diagnosis
- Rehabilitation Plan:
- Correction of remediable problems such as hypotension, vascular disease should be addressed with appropriate measures.
- Medications for vertigo and related disorders, such as prochlorperazine, promethazine, cyclizine or metoclopromide orally, intramuscularly or as a suppository are used as needed. Diazepam reduces neural activity by CNS suppression and is an anxiolytic drug.
- Specific exercise program: such as vestibular rehabilitation with exercises designed to provoke dizziness by repeating movements until not tolerated wherein the dizziness becomes worse; however, over weeks to months, the dizziness improves from central adaptation. This approach helps patients with peripheral and central vestibular dizziness. Gait and balance exercises are part and parcel of the exercise program.
- Education on fall prevention and environmental safety with stair railings, grab bars, railings for toilet seats and removing the tethers are an important part of management of dizziness.
- General fitness program
- Realistic patient & family social and occupational goals
Different disease stages
New onset/Acute: The majority of causes of dizziness are due to vestibular dysfunction. For these cases, pharmacologic and surgical interventions are rarely curative. Medical management often serves to suppress secondary symptoms rather than to treat the underlying cause. There is strong evidence to suggest that vestibular rehabilitation in combination with physical/repositioning maneuvers (Canalith repositioning procedure) may resolve symptoms and improve function18.For most all other causes of dizziness the role of rehabilitation is unclear and medical management is aimed at treatment of the underlying cause.
Vestibular dysfunction: NA
Acute stage: Medication management is often used with the aim to suppress the vestibular system and treat associated symptoms such as nausea. Surgery is of little role in the acute setting. There is strong evidence to support vestibular rehabilitation in combination with physical maneuvers to treat symptoms and aid in longer-term functional recovery. There is moderate evidence that these effects may be maintained post-intervention 18.
Sub-acute stage: There is no evidence detailing appropriate management for sub-acute dizziness, though it may be surmised that management would likely mirror that for chronic dizziness.
Chronic stage: Treatment consists of pharmacotherapy, vestibular and balance rehabilitation therapy (VBRT) (an exercise program performed at home by patients supervised by physical therapists), including the Epley maneuver (which involves sequential movement of the head into four positions, staying in each position for roughly 30 seconds. It is an excellent habituation/desensitization program for chronic dizziness. In addition, Cognitive-behavioral therapy may be helpful for dizziness due to anxiety and depression 12.
As with the acute stage, pharmacologic interventions play a limited role in the management of dizziness. Medication management is implemented to suppress symptoms and is not curative 18. Vestibular rehabilitation is a non-invasive curative therapy shown to improve subjective measures of dizziness, balance, and gait performance, as well as, activities of daily living, and visual impairments (Cochrane review). Such rehabilitation therapies have been found to be superior to medication management in terms of improving symptoms 18.
Coordination of care:
Patient, family, and the treating team of physiatrists, Otolaryngologists and neurologists play a role in team effort to manage dizziness
Patient and Family education:
Patients and family should be educated to be aware that dizziness can lead to loss of balance and falls with injuries. They should be advised to make their homes fall-proof by removing tripping hazards such as loose rugs, and long electrical cords. Emphasize to move slowly and avoid driving when they feel dizzy.
Management of treatment outcomes: including those that are impairment-based, activity participation-based and environmentally-based
- Correction and amelioration of co-morbid conditions, treating and avoidance of dehydration especially in the older adults.
- Physical therapy for balance exercises, gait training and vestibular rehabilitation
- Provision of gait aides such as canes and walkers for safe gait
Translation into practice: practice “pearls”/performance improvement in practice(PIPs) changes in clinical practice behaviors and skills)
Clinical Pearl: Head Impulse Test (HIT) (where in the examiner abruptly accelerates and then decelerates the head, moving the head in rapidly at high speed and then stopping it) is the most sensitive and specific bedside test for distinguishing central from peripheral causes in the acute vestibular syndrome when other focal neurologic or otologic findings are lacking 19.
4. GAPS IN THE EVIDENCE-BASED KNOWLEDGE
Controversies and gaps in the evidence-based knowledge
The Canalith repositioning procedure (CRP) has been demonstrated to be very effective in the treatment of benign paroxysmal positional vertigo (BPPV); however, there is still some controversy concerning the necessity of treatment. Some physicians believe that dizziness is often benign and self-limited and hence no therapy is required.
5. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Effectiveness of conventional versus virtual reality-based balance exercises with Nintendo Wii Fit Plus in vestibular rehabilitation for unilateral peripheral vestibular was studied and is found not to be superior to conventional vestibular rehabilitation but thought to provide a more enjoyable method of retraining after balance peripheral vestibular loss20.
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- Maarsingh, OR, Dros, J , F G, Henk Weert, V, Van der Windt DA., Riet, GT and Van der Horst HE. 1Department of Family Practice and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands Causes of Persistent Dizziness in Elderly Patients in Primary Care. Ann Fam Med. 2010; 8(3): 196–205.
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- Meldrum D, Herdman S, Vance R, Murray D, Malone K, Duffy D, Glennon A, McConn-Walsh R. Effectiveness of conventional versus virtual reality-based balance exercises in vestibular rehabilitation for unilateral peripheral vestibular loss: results of a randomized controlled trial. Arch Phys Med Rehabil. 2015 Apr 1. pii: S0003-9993(15)00289-0. doi: 10.1016/j.apmr.2015.02.032. [Epub ahead of print]
* Portions of this article have been presented at the Dizziness Conference, Garderen, The Netherlands, May 2009; and the European General Practice Research Network, Dubrovnik, Croatia, October 2009.
CORRESPONDING AUTHOR: Otto R. Maarsingh, MD, Department of Family Practice and Institute for Research in Extramural Medicine, VU University Medical Center (D556), Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands, Email: firstname.lastname@example.org
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