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Cracking the Code on Lightheaded Dizziness

When people say that they feel dizzy, most people, even healthcare providers usually think that you’re talking about the room spinning sensation of vertigo. However, there are thousands of people around the country describe themselves as having dizziness but don’t have the characteristic sensation of vertigo. Many patients may describe their dizziness as a rocking, swaying, floating, or disoriented feeling. More than anything, people with dizziness have a feeling of being out of sorts if it’s not specifically related to vertigo.

In this article, we are going to breakdown a specific and very common feeling that people associate with dizziness. We are going to talk about lightheaded dizziness.

Orthostatic Intolerance – a blood flow issue

Most people have had a feeling of light headedness at some point in their life. It’s most commonly felt when people go from laying down to standing too quickly. Your head feels funny and you might feel your vision get dark for a moment. After a few seconds, the feeling passes and you probably won’t even think twice about it.

This sensation of feeling light headed on standing is called orthostatic hypotension or orthostatic intolerance.These are terms used to describe the fact that when you change positions, your blood pressure didn’t meet the brain’s demand for blood in that moment in time.

Your brain is a greedy organ when it comes to blood flow. Although it only makes up about 2-3% of the body’s total mass, the brain hogs about 20% of the body’s blood flow. Your blood pressure is not just a marker for the health of your heart, but the purpose of a tightly regulated blood pressure is to make sure that your brain is getting that 20% blood flow at all times. 

While people generally think of their heart as the main controller of blood pressure, it is actually your nervous system that keeps it tightly regulated. It’s so regulated, that in the moments right before you stand (when the idea of standing was just a thought), your brain is sending messages to your muscles and arteries to tighten up so it can keep your blood pressure constant when you are changing postures.

Pretty neat right?

While most people can have moments of lightheadedness like this from time to time, it usually goes away on its own. However, some people feel this sensation on a regular basis. It’s been estimated that anywhere between 4% young adults and 30% of older adults experience orthostatic intolerance. About 42% of people with a complaint of dizziness have a complaint of light headed dizziness related to standing. [Source]

Whether you feel like you’re  spinning, rocking, or light headed, a persistent feeling of dizziness can lead to feelings of anxiety and depression because of the impact on your daily life activities. Orthostatic hypotension is also associated with increased incidence of cardiovascular events and overall mortality, especially in the aging population where feinting and dizziness can lead to falls

Why Does Orthostatic Intolerance Happen?

So far, research has shown that the light headed feeling from orthostatic intolerance is a blood flow issue in the brain. We also know that the autonomic nervous system is a major role player in this problem as many patients with this form of dizziness will have abnormal findings on head upright table tilt testing as well as abnormal blood pressure findings when using a valsava maneuver. [Source]

For many of these cases, there is a problem in the regulation of the sympathetic or parasympathetic nervous system. This gets further complicated by the fact that people who experience orthostatic hypotension may have the same symptoms, but the neurological mechanism that is causing the symptoms are different. [Source]. In general terms, the sympathetic nervous system may have problems constricting your arteries on standing, or the parasympathetic system may have difficulties in regulating your cardiac output. That’s why many patients with orthostatic issues may get evidence-based treatment for the condition.

How Is It Treated?

This part is difficult, because unless you’re in an area that does specialized autonomic laboratories, many people don’t even know this condition exists. Many people get misdiagnosed with vertigo. Many others will just have their condition brushed off.

If you’re lucky enough to have someone that understands orthostatic issues, then you will likely be managed with a regiment of blood pressure medication and IV’s to help keep your blood pressure from tanking. This gets complicated if a patient has HYPERtension when they lie down which is obviously problematic to give therapies that will non-specifically increase your blood pressure.

A Neurological Approach

While many doctors are concerned with blood pressure numbers in of themselves, from a chiropractic perspective we ask why the body is having an abnormal autonomic response to changes in posture. This is particularly important when we are thinking about the head.

When the head and neck shift, it can disrupt normal proprioception into the brainstem and have wide ranging effects of the autonomic nervous system. Excessive twisting or rotation of the Atlas vertebrae may also affect the jugular vein and how blood flow returns to the heart leading to problems with the vagus nerve and cardiac output.

We have also seen patients with dysautonomia have small disturbances in the function of their vestibular system. In some cases patients with orthostatic hypotension can experience vertigo, but in many cases it simply makes head and eye movement far less efficient.

When we put this all together, we have found that a cervical-vestibular approach has the potential to create important improvements in the autonomic nervous system which can help patients overcome their poor relationship with gravity.

Tell us about your dizziness

Dizziness: Misdiagnosed and Mistreated

Dizziness: Misdiagnosed and Mistreated

 

Dizziness is Hard to Diagnose

When people have dizziness as a complaint, it can be one of the most commonly misdiagnosed and mistreated conditions around. The challenge is that dizziness is a symptom that can be associated with lots of different conditions. Here’s a short list of conditions associated with dizziness:

Primary dizziness: Dizziness as a primary disease entity

  • Positional vertigo (BPPV)
  • Meniere’s disease

Secondary dizziness: Dizziness as a result of another problem

  • Stroke
  • Migraine
  • Concussion
  • Tumors
  • Medications

On top of that, dizziness means something different to different people. Does your dizziness feel like spinning? Rocking? Feeling off balance? Light headedness? Sometimes the feeling of dizziness can be hard to describe because you just feel disoriented and lost in space.

All of these factors are important to help a doctor get the right diagnosis.

It means that a doctor has to take a good health history, perform the right bedside tests, and order the appropriate diagnostic testing to find out the cause of your dizziness. Without knowing what’s causing this feeling, then administering the right treatment can be a lucky guess at best, or make you more dizzy at worst.

It’s no wonder that people who have chronic vertigo and other balance issues often see their primary care doctor, neurologist, ENT, physical therapist, acupuncturist, and more looking for answers on how to get their world to stop moving.

Dizziness is Even Harder to Treat

Another challenge with dizziness patients is that medications don’t really do a good job of making the world stop moving. Many patients with chronic dizziness are placed on anti-depressants, anti-anxiety meds, and drugs for nausea. The problem with that is that the patient may not be as nauseated, but their brains are not responding to their environment appropriately.

Dizziness after spinning on a bat is easy to explain, but what if the world is spinning when you're standing still?

Dizziness after spinning on a bat is easy to explain, but what if the world is spinning when you’re standing still?

 Dizziness can also be treated by positional maneuvers like the Epley maneuver and head shaking exercises like gaze stability. Both are extremely effective when they are used appropriately, but can be useless if it’s performed on the wrong patient with the wrong diagnosis.

That’s why it’s so important to know what’s really going on with a patient. Many clinics will take any person with dizziness and just do some of these maneuvers even though the maneuvers may not be appropriate for the patient’s specific condition. In order to help a patient recover, we have to examine them closely to make sure that we have the right information to begin care.

Case Study: 

Recently we had a patient come in with dizziness and had been seeing an ENT for treatment. She was having problems feeling off balance for a while and it was made with head turning sometimes. She wasn’t experiencing a spinning type sensation, but just a sense of feeling out of sorts.

The doctor diagnosed her with benign paroxysmal positional vertigo or BPPV. It’s arguably the most common form of vertigo and is usually easily treated with a positional maneuver called the Epley maneuver. The doctor performed Epley and gave her some alternative maneuvers that she could do at home whenever she felt dizzy.

The problem was that the maneuver wasn’t changing anything. She tried doing the maneuvers for several weeks with no change. When she followed up with the doctor, the doctor told her there wasn’t anything else he could do and that some cases don’t respond.

Fortunately the patient found her way to our office through a referral from one of our patients who got really great results with balance problems

BPPV usually causes a spinning sensation that is really short lived. In many cases, doctors can diagnose BPPV with a test called the Dix-Halpike maneuver. You can look at this test below. If you have BPPV your eyes will start moving making a fast oscillating movement called nystagmus.

It’s this nystagmus when the inner ear moves the eyes that creates a feeling of spinning.

When this patient came in, we did a thorough history and found out that her “vertigo” didn’t have any spinning at all. She just felt disoriented and off balance. We performed the Dix-Halpike test and she had her eyes stayed solid.

So now we knew that she probably didn’t have BPPV, and that’s why the Epley maneuver didn’t work that well for her. It was time to figure out what other anatomy might be causing her problem.

We did a test called the smooth pursuit neck torsion test. It’s a test developed from patients who had dizziness after whiplash. It’s an indicator that the neck might be causing the eyes to move abnormally. You can see that test here below. In patients with neck problems, the eyes will start jumping instead of staying smooth.

Now that we knew the neck could be a problem, we started addressing the neck using the NUCCA procedure for structural correction.

Within 2 visits, the patient’s dizziness was about 80% gone. We have more work to do to help the neck heal, but with some time I think this patient will get back to normal.

Find the Cause, Deliver the Solution

So this isn’t an indictment on another professional. Lots of ENTs keep their focus on infections of the ear, nose, and throat. An ENT with a neurology background would probably have found the same thing and recommended physical therapy or chiropractic care.

The lesson here is that dizziness is complicated, and one treatment won’t solve all forms of dizziness. For any condition, we have to spend time with our patient, listen to their history, examine them thoroughly, and we can find a game plan to help them get back to normal.

Talk to Dr. Chung