Articles written by me on Self-care and Palliative Medicine
On Self-Care & Palliative Medicine

Spinning a Few Yarns

We’re all dizzy headed at one time or another. Certainly, and stereotypically, blonds have an edge, but a dizzy-headed feeling is pervasive in our society. Did you know that 40% of people over the tender young age of 40 experience dizziness or balance problems on occasion? In fact “dizziness” is the third most common reason that people over age 65 visit their doctor. Symptoms may occur with allergies (both environmental and food), tumors, after trauma, strokes, major drops in blood pressure, exposure to certain toxins, as part of Meniere’s Disease, or because of infections (with good ole ‘cold viruses’ topping the list), but the majority of cases are idiopathic (meaning that ‘nobody knows why’). Dizziness that creates the sense that either you or your surroundings are spinning distinguishes vertigo from other forms of dizziness. So, the essence of vertigo is illusionary movement.

Benign positional vertigo is the most common cause of vertigo, occurring twice as frequently as any other vestibular disorder. The average age of onset for Benign Paroxysmal Positional Vertigo (BPPV) is 51 years with increased incidence with advancing age. Intense but brief episodes of vertigo are associated with changes in head position, usually when lying down. Symptoms resolve within 3-6 months, but may recur. I’m going to concentrate on this form of vertigo because it is the most common type, and because a set of exercises can moderate the symptoms or even “cure them” over time.

Before moving forward, let’s whirl through a brief review of the basics of balance. Under normal circumstances, our sense of balance is controlled by signals sent to our brains from our eyes, our sensory nerves, and our inner ear complex. No matter what position we’re in, our eyes send visual signals to orient our bodies in space. When you’re in the midst of the upside down roller coaster corkscrew, those signals can be pretty bizarre! Secondly, we have an extensive network of sensory nerves in our skin, muscles, and joints. These nerves are constantly sending information to our brains about body positioning and body movement. When you’re walking, your feet feel the pressure; when you’re lying down, your back and buttocks send pressure sensation messages back to the master computer, etc. And the final component, our vestibular labyrinth, is our organ of balance. . .truly the body’s gyroscope! Located in the inner ear, it’s an intricate structure of loop-shaped semicircular canals containing fluid and hairlike sensors,the utricle with its otoconia, and the snail-shaped cochlea. Sound like names of characters in the new Star Wars movie? Each component contributes in a specific way. The semicircular canals help us keep balance when we’re turning. The utricle contains tiny particles of calcium carbonate crystals called otoconia that are attached to sensors. These sensors detect back and forth motion. The cochlea is the lower part of the inner ear and is primarily a hearing organ. Now that your head is spinning with these important medical facts, steady yourself for what follows.

Staggering ahead, vertigo due to head movement is called positional vertigo. BPPV is characterized by sudden short bursts of vertigo that typically occur with head movement. Some nausea (with or without vomiting) and a lingering fatigue may accompany the vertigo. Episodes can come and go unpredictably for weeks or even years. BPPV occurs when the otoconia that normally reside in the utricle break loose and, most commonly, migrate into the posterior semicircular canal. After this happens, certain movements–such as looking up, rolling over in bed, and bending forward can cause these particles to bend the hairlike sensors in the canals and cause the spinning episodes.

There’s an immediate treatment geared at getting the otoconia back into the utricle where they belong. Think of the childrens’ toys that contain hundreds of small beads. The object is to roll them from one part of the toy into another. The Epley maneuver, which is basically a tilt and turn technique done in your doctor’s office can sometimes reposition the otoconia where they belong. . .and cure you before you ever leave the office. Simply put, your utricle has lost its marbles and needs them back before it can restore equilibrium and keep you from losing yours.

Diet, medications( such as Antivert and Valium that suppress the vestibular system), certain supplements and vitamins, and vestibular rehabilitation can all help treat various forms of vertigo. In rare and extreme cases, even surgery is indicated. I’ll comment specifically on the balance training/exercise arm of therapy because I think it’s underused in chronic vertigo situations, though it’s probably the most valuable treatment in such situations.

The aim of rehab. is to train other redundant systems to take over when there’s a vertigo/balance problem. This is especially beneficial when one inner ear mechanism’s out of whack but the other’s normal. The good ear plus other systems are more than sufficient for balance even when the positional vertigo is chronic and extreme. In people with multiple deficits (rather than isolated to a single inner ear), the vertigo might not be curable, but rehab. exercises can help to keep people mobile and prevent falls by generating improved efficiency of the remaining balance centers.

The programs generally includes balance activities and/or eye movement exercises. Using remaining vestibular function, balance activities help a person with vertigo maximize the use of remaining vestibular function, their sight, and the sensation in their feet to maintain balance. Eye exercises help a dizzy person’s brain to reprogram the reflexes associated with eye movement. ENT Clinics generally offer individualized vestibular rehabilitation to patients who suffer from persistent vertigo–though the rehab. program is usually offered only after an extensive evaluation to exclude other causes such as stroke, tumor, or infection to the brain and/or inner ear mechanisms. Obviously, you don’t want to misdiagnose a vertigo disorder which would require radically different therapy. Okay. . .on to the exercise example.

BALANCE TRAINING EXERCISES

Head motion stimulates the balance canals of the inner ear. Like a figure skater just learning to spin on skates, you can expect it will take some time for your balance to improve. The brain must learn to overcome the feeling of dizziness. Virtually all patients using these exercises will note improved balance, but it may take a few weeks.DON¼T GIVE UP! It is important to start slowly because quick head movements can make anyone lightheaded at first. Slowly increase the speed and duration of exercises as tolerated. It is common for people to become dizzy during some of these exercises; this is a required part of the healing process–so don’t let apparent setbacks discourage you!

Exercises

Cawthorne’s exercises should be carried out for 5 minutes, 10 times per day. You can expect dizziness when beginning; this feeling should lessen over time with repetition. Please be seated while doing them.
Eye Exercises: Look up, then down-at first slowly, then quickly 20 times. Look from one side to the other-at first slowly, then quickly 20 times. Try to focus on an object at the end of each head turn.
Head Exercises: With eyes open, bend head forward, then backwards — at first slowly, then quickly 20 times. Turn head from one side to the other — at first slowly, then quickly 20 times. As dizziness lessens, these head exercises should be done with the eyes closed.
Sitting / Bending Exercises: While sitting, shrug shoulders 20 times. Turn shoulders to the right, the to the left 20 times. Bend forward and pick up objects from the ground and sit up, 20 times.
Standing Exercises: Change from a sitting to a standing position, and back again, 20 times. Do this initially with eyes open. As balance improves, do this with eyes closed (but only if you have a partner to help you). Throw a small rubber ball (or similar object) from hand to hand above eye level. Throw the object from hand to hand under one knee.

Okay, so you’ve made it to the end and now know some important self-help skills for vertigo. When colds and sinus infections are the cause of your symptoms, your vertigo will generally be intense (but brief) and will resolve when the infection clears. In BPPV, the symptoms are more prolonged and/or recurrent, but these exercises can cure you over time. Just hold to the belief that you will be sure-footed in the future, and balance your sense of spinning with your sense of humor in the meantime. Remember, even when you’re awash with the staggering and nausea of acute inner ear miseries, your ‘spin cycle’ won’t last forever. And, always remember, it’s better to spin a yarn than to pull the wool over your eyes. . .especially when you’re already dizzy!

Stephen L. Hines, M.D.
June 2002

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