As you read that word, I’m sure an image or feeling pops into your head. Everyone makes an association when they think about being dizzy, and yet “dizziness” is one of the most loaded symptoms on your patient’s SCAT self-rated symptom scale.
Dizziness is often part of the conversation when you’re talking about concussion, and for good reason. It a commonly-reported symptom, and patients who are dizzy on-field, at the time of injury, are significantly more likely to have a prolonged recovery time (Lau et al, 2011).
Dizziness is also notoriously difficult to define. By it’s nature, the word is imprecise, and refers to a variety of subjective experiences. (In this way, it’s a bit similar to pain. Also like pain, you can’t argue it away. All you can do is work to understand it better.)
This makes dizziness as a symptom very difficult for patients to describe. When they try, they often use language that’s vague or doesn’t make much sense.
It is sometimes thought that dizziness refers to only one of the following: presyncope, vertigo, disequilibrium, or non-specific dizziness. This school of thought also asserts that each of these terms is associated with a specific pathophysiology, so if you can confirm, for example, that your patient’s report of dizziness actually refers to presyncope, than you know your patient has a cardiovascular problem. In reality, not surprisingly, it’s not so simple.
So, how do you know what dizziness means to the patient sitting in front of you?
You ask. And then you listen to their answers.
The following is a starting point to talking about dizziness. Feel free to leave a comment with any questions, words, or strategies that have proved useful in your own practice.
(adapted from here)
Breaking it down:
Is the patient describing a feeling in their head?
- Lightheadedness may be a sign of presyncope, but can also be related to anxiety or depression
- Patients may also report feelings of floating, swimming, and/or spinning inside the head
Is it more like a sensation or perception in their environment?
- Do they feel like they’re rocking or swaying, as if on a boat?
- Do they feel like things they’re looking at are moving? Oscillopsia is the illusion of visual motion, and it occurs only with the eyes open.
- In contrast, vertigo occurs with the eyes open or closed. It is the illusion of movement - either of oneself, or of the world or environment around you
- Diplopia is double vision. While different, some patients may use the word “dizziness” to describe seeing double
Is balance affected?
- Disequilibrium is imbalance or unsteadiness while walking
Are they nauseous?
- Patients may also report nausea (with or without vomiting) or motion sickness. While a separate symptom on the SCAT Symptom Scale, it’s worth asking about nausea when you’re talking about dizziness
This next bit may go without saying, but hear me out:
Concussions can cause dizziness, but not all dizziness is due to a concussion.
As a practitioner, you understand this. A patient may not.
It’s not unusual for someone to experience dizziness, remember hitting their head, and self-diagnose a concussion because they read something online connecting dizziness and concussion. Or maybe they consulted Dr. Google, read that dizziness occurs with concussion, and came to see you for a concussion assessment. Maybe they’re right - but maybe they’re not.
Also, concussions can co-occur with other vestibular, cardiovascular, or mental health conditions that can cause symptoms that may be classified as “feeling dizzy.” Concussions can also exacerbate conditions from a patient’s past which seemed to be resolved (but more likely they had compensated for, and the brain injury disrupted that compensation).
Remember to take a good history and do a good assessment - don’t get caught with tunnel vision! Develop a list of differential diagnoses, and use your assessment to rule them out, especially if you weren’t on the sidelines watching the patient’s injury take place.