Assessing Dizziness: A Guide for MSK Therapists

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According to the Vestibular Disorders Association (VeDA), 35% of American adults over the age of 40 have experienced some form of vestibular dysfunction (1) – no one’s done the study, but it’s probably safe to assume the numbers are similar in Canada. This probably includes a handful of your past or current caseload. For example – sometimes when people are injured in a fall, the fall happened because they were dizzy.  

In other words, an undiagnosed and unmanaged vestibular disorder can impact an MSK treatment plan. Dizziness can be intimidating, especially if you’re not familiar with it. But you don’t have to ignore dizziness, or even refer the client off your caseload. It’s totally possible for an ortho-focused therapist to play an important role in the management of the dizzy patient or client. 

First of all, remember that vestibular problems present in many different ways.

Some people will actually tell you they feel dizzy, but others may say they feel floaty, off-balance, spinny, or use some other word. Many won’t volunteer any information at all. It’s a difficult experience for patients to describe, and they often fear sounding like they’re crazy, so they say nothing at all. So you need to ask. Ask often, and ask in different ways. 

It’s a good idea to ask about dizziness just like you ask about pain. Pain and dizziness are imprecise symptoms and can refer to a variety of subjective experiences. When taking a clinical history for any type of injury, ask if they currently feel or have recently felt dizzy. 

Try different words, too. Dizziness, lightheadedness, feeling floaty or wobbly or woozy – use a few different words, the sillier the better. In my experience, using a silly, non-medical word gives the person in front of you implicit permission to talk to you the way they talk to themselves. 

Then, ask more questions

If they have one of these weird “dizzy-ish” experiences, don’t leave it there. Just as you would with a report of pain, ask about the frequency, intensity, and any aggravating or easing factors. Probe a little bit into what they mean with their symptom descriptor: 

  •   Is it a feeling in their head? Some patients may describe floating, spinning or swimming feelings. 

  • Lightheadedness can sometimes be a sign of presyncope, but this is not a hard and fast rule - it can also be cervicogenic in origin. 

  • Are they describing a sensation or perception in their environment? Do they feel like they’re rocking or swaying? This can be linked to dysequilibrium and compromised balance. Does the patient feel like the things they’re looking at are moving? Oscillopsia is the illusion of visual motion which occurs when the eyes are open. 

  • Does the patient perceive movement - either that they’re moving, or that the environment is moving around them? This is the true definition of vertigo, and it can occur with the eyes open or closed. 

  • Finally, some patients use the word “dizzy” to describe double vision, even though we’d consider it a different symptom. Understanding what your patient is experiencing can help you manage it most effectively.

Finally, look objectively (and treat if you’re comfortable)

Once you have a good idea of the patient’s experience with dizziness, use your objective exam to rule out neurological causes of dizziness or lightheadedness (like cerebellar dysfunction or stroke) or vascular or cardiovascular causes (like vertebral artery insufficiency or orthostatic hypotension). A thorough cervical spine assessment can point towards or away from cervicogenic dizziness as well, and if these causes are ruled out, the dizziness may be vestibular in origin. 

If you’re comfortable with it, Dix-Hallpike testing can rule in benign positional paroxysmal vertigo (BPPV), but won’t always rule it out; testing for BPPV can sometimes require more extensive assessment than just the Dix-Hallpike test. Additionally, there are other causes of vestibular dysfunction, and patients with persistent, intractable, long-standing, or debilitating dizziness should be seen for a full vestibular assessment. Management of vestibular dysfunction often includes specific vestibular rehab maneuvers and exercises, but this is a population at high risk for becoming sedentary and house-bound. Balance, safe ambulation, and regular daily exercise are always worth discussing with patients, especially as they may need help and advice about safe activities or adaptations.

It’s not always a concussion…

Of course, dizziness is also a common symptom of concussion, and patients who are dizzy at the time of a concussion injury are significantly more likely to have a prolonged recovery time (2). These patients are more likely to end up in your clinic, struggling with persistent post-concussion symptoms. While managing concussion-related dizziness is a significant challenge, it’s important not to get tunnel vision with regard to dizziness and concussions. 

As a practitioner, you know that concussions can cause dizziness, but not all dizziness is caused by concussion. Clients may not necessarily understand this, though. With the attention concussions get in the media, a patient may self-diagnose a concussion when trying to figure out why they suddenly feel dizzy, and present to your clinic for a concussion assessment. Careful questioning and a good history, though, can usually help you get to the bottom of these situations.

 

Even if you don’t regularly assess for dizziness, you may have one or two end up in your schedule. They might present as a mis-diagnosed concussion patient who actually has a vestibular disorder, or an older client who is seeing you for an orthopaedic injury from a fall due to orthostatic dizziness or compromised balance. Dizziness and vestibular dysfunction may affect more of your caseload than you realize, but with awareness and careful questioning you can start the conversation, help your patients realize dizziness is not their new normal, and make your orthopaedic treatment plan even more effective. 

 

References

(1)Vestibular Disorders. Retrieved May 16, 2018, from www.vestibular.org

(2)Lau BC, Kontos AP, Collins MW, Mucha A, and Lovell MR (2011). Which On-Field Signs/Symptoms Predict Protracted Recovery from Sport-Related Concussion Among High School Football Players? The American Journal of Sports Medicine, 39(11), 2311-2318.