Dizziness and vertigo

We start by asking what the dizziness feels like, what brings it on, how long each spell lasts, and how it started. If the dizziness began after a blow to the head, we also check for a concussion. See concussion rehabilitation.

Then we check:

• how steady you are standing and walking
• your eye movements, with your head still and moving
• positional tests, moving you from sitting to lying with your head turned, to look for loose crystals
• your neck, and whether moving it brings on dizziness

Some dizziness comes from the brain itself: vestibular migraine, a stroke, multiple sclerosis and other neurological conditions. These need a careful assessment and a rehabilitation plan, and if they have not been diagnosed, a referral to your doctor or the emergency department first. Dizziness can also come from blood pressure, the heart, medicines or other medical problems. If your symptoms do not fit an inner-ear, balance or neck pattern, we ask you to see a doctor or nurse practitioner.

Treatment depends on the cause:

• Crystals loose in the inner ear (BPPV): tiny calcium crystals drift into one of the inner ear's balance canals. Then lying down or rolling over sets off a short spin. We treat this with a set series of head and body positions that guide the crystals back out of the canal (repositioning manoeuvres).
• Inner-ear infection or inflammation (vestibular neuritis): the balance nerve of one inner ear becomes inflamed, often after a virus. Once the worst spinning has passed, we use balance work and gaze exercises, where you keep your eyes on a target as your head moves.
• Other inner-ear disorders: labyrinthitis, Ménière's disease and vestibular hypofunction (an inner ear that has stopped working well) are treated the same way, with gaze and balance exercises matched to the tests, alongside your doctor's care.
• Dizziness from the neck: the neck tells the brain where your head is, and a stiff, sore neck can blur those signals. We treat the neck with manual therapy and exercise.
• Balance problems in older adults: balance can slip with age, time in bed, or changes in eyesight or feeling in the feet. We set strength and balance exercises to help lower the chance of a fall.
• Motion sensitivity: some people feel dizzy or sick in a car, on a gondola, in busy places or on screens (visually induced dizziness), and some are left with a constant swaying or rocking feeling for months (persistent postural-perceptual dizziness, PPPD). We use short, repeated doses of the movement that bothers you (habituation exercises). Each dose should make your symptoms no more than a little worse.

Most of this is vestibular rehabilitation therapy: exercise-based treatment for the inner ear and balance system.

Before you return to the hill or trail, your balance and vision need to keep up with quick head turns. We test these, then build drills such as head turns while you balance, quick direction changes, and work on uneven ground.

Flat light on the ski hill takes away the visual cues you use for balance. We add drills with your eyes closed or your vision busy. Start back on easier terrain, in good light. The same training helps with everyday balance, such as walking on snow and ice.

Book an assessment if lying down or looking up sets off a spin, or you still feel unsteady after an inner-ear illness. Come in too if dizziness comes with neck pain, your balance has slipped, or movement around you makes you queasy.

Go to the emergency department right away, or call 911, if any of these happen:

• a sudden, severe headache or neck pain
• double vision or loss of vision
• trouble speaking or swallowing
• weakness or numbness on one side of the face or body
• sudden trouble walking or standing, or a clumsy arm or leg
• chest pain, a racing or irregular heartbeat, or fainting
• new, severe dizziness with hearing loss