: Emily was initially noted to have BPPV which was treated and then went away. However, her dizziness persisted, albeit differently than it was before she had her BPPV treated. She wonders if the two are related; and how to know if the treatment of BPPV was successful?
Yes, this is very common. For example, we have had many patients with BPPV
(Benign Paroxysmal Positional Vertigo, an inner ear condition) who went on to develop a second reason for their dizziness, a non-inner ear-related cause for their dizziness, above and beyond BPPV. About 18% of BPPV is said to be due to concussions (Baloh et al., 1987).
Other common conditions that can trigger non-inner ear-related dizziness are (Staab et al., 2007; Staab et al., 2009)
- Vestibular neuritis (~7-10%);
- Migraine (~15%);
- mTBI (~15%);
- Panic disorder (~15%);
- Generalized anxiety disorder (~15%);
- Autonomic dysfunction (~ 7%);
- Dysrhythmias (i.e., cardiovascular causes) ;
- Other general medical conditions or an adverse drug reaction (~ 2%).
Inner ear conditions like, BPPV, tend to be felt more like vertigo. Vertigo is the illusion of movement of oneself or the environment upon moving one’s head, due to an abnormality somewhere between the inner ear and the cortex, where vertigo is perceived.
There are several diagnoses for types of dizziness that come from areas other than the inner. This is discussed at length in our podcast episodes on dizziness, episodes 13 & 14
. One of the most common of these diagnoses is Chronic Subjective Dizziness (CSD).
There are many other synonyms for CSD, and many other terms to describe specific features of CSD. CSD is described as a vague, daily, unsteadiness (i.e., swaying or rocking) that is always there but can wax and wane depending on many factors (i.e., stress, fatigue, position). It is called CSD when it has been there for at least 3 months. CSD can:
- Occur when the patient moves or their surroundings move, it does not relate to a specific movement direction or position like for inner ear-related causes of vertigo, however, it tends to be worse in standing/walking than it is in sitting, which in turn, tends to be worse than when lying down.
- Be aggravated by exposure to large-field moving visual stimuli (e.g., like the commotion in a train station) or complex visual patterns (like busy tiling/décor in hotel lobbies or museums like the Royal Ontario Museum).
- Be aggravated by exposure to small-field, precision, visual activities (e.g., reading, using a computer, fine motor tasks with the hands – like cutting hair, sewing, machine repair, etc.).
Vestibular tests for CSD are usually found to be normal; most of the abnormalities seen are functional deficits that tally with reports by the patient of what they can or cannot do. Normal vestibular tests may cause patients to feel brushed off, or that the cause for their dizziness was “missed” by those tests. Patients tend to feel more validated when an objective abnormality is found. However, the way to validate patients is to educate them about their experiences as we are doing in this article. Once they appreciate the nature of their problem, patients are then more receptive to the factors that influence it and how to improve it.
: Emily was educated about what BPPV is and how common it is in the post-concussion population. Although the name implies that it is benign, it did not feel “benign” to her as it triggered persistent dizziness of a different nature. She was explained that they were in fact different causes of dizziness: BPPV is treated with repositioning maneuvers and the symptoms are sort of there or not-at-all (i.e., situation is more ‘black-and-white’); her other dizziness needed to be treated differently and would be there in varying levels of severity depending on many other factors like fatigue and stress (i.e., ‘shades of grey’). As is the case with post-concussion patients, BPPV crystals tend to be more recurrent and involve multiple canals and be a little more resistant to treatment (Katsarkas 1999). So, when Emily had a recurrence of BPPV, she was able to take it in stride and not fear that both her conditions were getting worse, and that all her treatment for the second cause of dizziness was not all for naught. She would come into the clinic and have the specific canal that was affected identified with our video frenzels. Being able to see the abnormality on video made her feel validated. The crystal was then repositioned, knowing full well that she may need to have this done a few times before it takes. She also knew that this process of recurrent BPPV would eventually peter out and that the worst thing she could do is worry about it. Being able to see the resolution of her telling eye movements using the video frenzel system after successfully repositioning the crystal also made her feel validated. And it was easier for her to understand now that her CSD is actually getting much better by helping focus her on objective markers of improvement like the fact that she was back at work and back to exercising, both of which she found enjoyable.