The term dizziness is often used to describe a feeling of “spinning, unsteadiness, lightheadedness, disorientation, floating or being foggy headed”. Dizziness can be the result of a disturbance in any part of the balance system, which is comprised of vision, muscles and joints and the vestibular system (inner ear). Dizziness can be debilitating and reduce a person’s ability to do their activities of daily living by avoiding movements that cause dizziness, so it is important to get a proper diagnosis and to start treatment to regain your quality of life and resume your normal daily activities.
Physiotherapists with special training are able to diagnose and differentiate dizziness. Diagnosis is based on the information given by the patient regarding the onset and frequency of the symptoms, aggravating movements and the duration of the episodes. The physiotherapy assessment consists of testing balance reactions, functional testing, gait assessment, cervical spine range of motion and eye reflexes with head turning. Generally, an episode of dizziness lasting for less than one minute is associated with Benign Paroxysmal Positional Vertigo (BPPV). Dizziness lasting for several minutes is often associated with vascular causes or cervical joint dysfunction. Dizziness lasting hours with a gradual decrease in symptoms might be a labyrinthitis or neuritis. Medications can also be a cause of dizziness.
The key to preliminary diagnosis is determining whether the patient’s complaints are of vertigo. Vertigo is the sensation of spinning or rotating. Crystals (Otoconia) in one inner ear may have 
become displaced into a semicircular canal from the vestibule, causing the sensations of vertigo. The Dix-Hallpike test is one method of diagnosis, the test is performed with the patient sittingupright with the legs extended. The patient's head is then rotated by approximately 45 degrees. The clinician helps the patient to lie down backwards quickly with the head held in approximately 20 degrees of extension. This extension may either be achieved by having the clinician supporting the head as it hangs off the table or by placing a pillow under their upper back. The patient's eyes are then observed for about 45 seconds as there is a characteristic 5-10 second period of latency prior to the onset of nystagmus. If rotational nystagmus occurs then the test is considered positive for benign positional vertigo. During a positive test, the fast phase of the rotatory nystagmus is toward the affected ear, which is the ear closest to the ground. The direction of the fast phase is defined by the rotation of the top of the eye, either clockwise or counter-clockwise. There are several key characteristics of a positive test:
Latency of onset (usually 5–10 seconds)
Torsional (rotational) nystagmus. If no torsional nystagmus occurs but there is upbeating or downbeating nystagmus, a central nervous system (CNS) dysfunction is indicated.
Upbeating or downbeating nystagmus. Upbeating nystagmus indicates that the vertigo is present in the posterior semicircular canal of the tested side. Downbeating nystagmus indicates that the vertigo is in the anterior semicircular canal of the tested side.
Fatigable nystagmus. Multiple repetition of the test will result in less and less nystagmus.
Reversal. Upon sitting after a positive maneuver the direction of nystagmus should reverse for a brief period of time.
To complete the test, the patient is brought back to the seated position, and the eyes are examined again to see if reversal occurs. The nystagmus may come in paroxysms and may be delayed by several seconds after the maneuver is performed.
If the test is negative, it makes benign positional vertigo a less likely diagnosis and central nervous system involvement should be considered.
Physiotherapists and some chiropractors now use a version of the maneuver called the "modified" Epley that does not include vibrations of the mastoid process originally indicated by Epley, as they have since been shown not to improve the efficacy of the treatment. The following sequence of positions describes the Epley maneuver:
The patient begins in an upright sitting posture, with the legs fully extended and the head turned 45 degrees towards the affected side.
The patient then quickly lies down backwards with the head held approximately in a 30 degree neck extension (Dix-Hallpike position) where the affected ear faces the ground.
Remain in this position for approximately 30 seconds.
The head is then turned 90 degrees to the opposite direction so that the unaffected ear faces the ground, all while maintaining the 30 degree neck extension.
Remain in this position for approximately 30 seconds.
Keeping the head and neck in a fixed position, the individual rolls onto their shoulder, in the direction that they are facing.
Remain in this position for approximately 30 seconds.
Finally, the individual is slowly brought up to an upright sitting posture, while maintaining the 45 degree rotation of the head.
Hold sitting position for up to 30 seconds.
The entire procedure should be repeated two more times, for a total of three times.
During every step of this procedure the patient may experience some dizziness.
Following the treatment, the clinician may provide the patient with a soft collar, often worn for the remainder of the day, as a cue to avoid any head positions that may once again displace the otoconia. The patient may be instructed to be cautious of bending over, lying backwards, moving the head up and down, or tilting the head to either side. The soft collar is removed prior to bed. When doing so, the patient should be encouraged to perform horizontal movements of head to maintain normal neck range of motion.
It is important to instruct the patient that horizontal movement of the head should be performed to prevent stiff neck muscles. This is a very successful treatment for this condition.
The upper cervical spine C1-2 can be a problem area, often due to faulty seating positions, and requires treatment to reduce dizziness.
Vestibular rehabilitation is an important part of treatment of vestibular disorders, i.e. labyrinthitis or neuronitis. An individualized treatment plan focusing on vestibular exercises will be determined and when used repeatedly it will reduce the patient’s sensitivity to motion through habituation. Exercises to re-train balance, improve muscle strength and joint range of motion and increase endurance may be necessary due to compensations in movement and avoidance of activities. Proper sitting positions will also help to reduce the tension on spinal muscles, particularly the cervical muscles which can compress the upper cervical nerves, leading to dizziness.