Categories: Anxiety, Concussions, Dizziness, Success Stories
Caitlyn, a 38-year-old psychology professor with a focus on human emotion, was used to seeking scientific proof and conducting thorough research. So when she started experiencing persistent dizziness and nausea, she began a methodical search for answers.
It all started in April 2019 with a 24-hour spell that left her with a vague, lingering sense of dizziness, tension headaches, and severe TMJ symptoms. Despite multiple consultations with neurologists, optometrists, and general practitioners, along with MRIs and other tests, the cause of her symptoms remained elusive.
In the meantime, her symptoms only got worse. “I began to have intense anxiety spells that sometimes coincided with visual symptoms, sensitivity to sound, and I started to experience aphasia [an inability to find words] during these spells,” Caitlyn remembers.
Despite trying various treatments, including vision therapy and medications, Caitlyn found herself at a standstill, struggling to balance her research with the symptoms that plagued her daily life.
Caitlyn’s story may be all too familiar to those who suffer from Persistent Postural-Perceptual Dizziness (PPPD), functional dizziness, or visually induced dizziness (VID).
“PPPD often follows some sort of episode that causes vertigo or dizziness,” explains Dr. Jeremy Schmoe, DC, DACNB. This might be something like benign paroxysmal positional vertigo (BPPV), loose crystals in the inner ear, vestibular neuritis, a traumatic experience, or significant stress. The problem with PPPD is that the brain can essentially “learn” this dizziness, and get stuck playing it on repeat.
“Sometimes the central structures in the brain get locked into this perceptual idea that you’re still dizzy, even after the initial trigger has been resolved,” Schmoe adds. This is why most specialists and conventional testing often lead to dead ends with PPPD—structurally, everything looks fine. “The majority of people who come to see us have seen ENTs and neurologists and everybody says things look fine, yet they’re still dizzy,” says Schmoe.
The vicious cycle of PPPD: symptoms, triggers, and the brain’s response
Symptoms of PPPD can include random dizziness, unsteadiness, disorientation, and cognitive confusion, often triggered or exacerbated by standing, walking, or exposure to visual motion. They result from the vestibular system and brain being unable to recalibrate and control the various systems necessary for integrating and interpreting one’s physical environment.
When these symptoms are left unaddressed, PPPD patients often acquire secondary symptoms of functional gait disorders, anxiety, avoidance behaviors, and severe disabilities. This can be exacerbated by experiences with well-meaning healthcare providers who inadvertently make things worse. “We see many people with health anxiety because they’ve been hurt by other providers. They’ve gotten treated or adjusted in ways that just made them worse,” says Schmoe.
Some emotional and cognitive symptoms of PPPD can be traced to the structure of the brain. An area called the cerebellum helps coordinate motor activity, maintain balance, and process sensory information related to movement and spatial orientation. The cerebellum is highly connected to the limbic system, which plays a crucial role in regulating emotions and stress responses.
This connection can contribute to the anxiety, fear, or emotional distress that sometimes accompany dizziness or vertigo—and also explains how stress can be a trigger for dizziness. The link between the cerebellum and limbic system can create a vicious cycle where dizziness leads to anxiety, which further disrupts sensory processing in the cerebellum, perpetuating the symptoms of PPPD.
Other cognitive functions can take a hit as well. “Your cognition, motivation, focus, energy, and attention get sapped when you have dizziness and vertigo,” says Schmoe. “Your brain thinks that you’re moving all day, which essentially drains its battery.”
Diagnosing the root cause of complex dizziness
At The Functional Neurology Center, we take a comprehensive approach to diagnosing complex dizziness and vertigo. Even if previous testing with other providers didn’t reveal any physiological problems, the advanced technology at our clinic has the potential to uncover issues that might have been missed.
“It’s important to look at everything from someone’s neck to the feedback from their muscles to see how they’re building an internal map of where their body is in space,” says Schmoe. Other advanced diagnostics can take a deep look into the vestibular system and visual pathways in the brain.
Here are some of the advanced diagnostic tools for complex dizziness used at The FNC:
Retitrack is an advanced eye-tracking system that records and analyzes fixational eye motion at the retinal photoreceptor level. By measuring the electrical activity in the brain’s visual cortex in response to visual stimuli, this test helps determine the integrity of the visual pathway from the eyes to the brain.
Since PPPD can be triggered or exacerbated by visual stimuli (such as busy environments or moving patterns), identifying issues in how the brain processes visual information can help understand the root cause of these triggers.
The Video Head Impulse Test (vHIT) is a diagnostic tool used to evaluate the function of the vestibular system, specifically the semicircular canals, which are crucial for maintaining balance and stabilizing vision during head movements.
Subtle dysfunctions or hypersensitivities in the vestibular system can contribute to symptoms of dizziness and vertigo. vHIT can detect these subtle issues. The test measures the vestibulo-ocular reflex, which stabilizes vision during head movements by producing eye movements in the opposite direction. Even minor dysfunctions in this reflex can exacerbate dizziness or visual disturbances.
If vHIT reveals specific weaknesses or abnormalities in aspects of vestibular function, this can help guide effective vestibular rehabilitation therapy.
Other tools include VNG (Videonystagmography), Saccadometry, and SVV (Subjective Visual Vertical). VNG evaluates inner ear function and eye movements to determine if dizziness is linked to vestibular disorders. Saccadometry measures the accuracy and control of saccades, or rapid eye movements, providing insights into potential dysfunctions in visual processing. And SVV assesses how the brain perceives verticality, identifying disturbances in spatial orientation and central sensory integration.
In Caitlyn’s case, the advanced diagnostic testing she received at The FNC revealed several issues that other providers had missed.
“The team was able to test my eye movements in ways that I had not been tested before,” she says. This testing revealed that she had faulty oculomotor control. Additional testing found that her movements were mistimed, her gait was abnormal, and she had rigidity on the right side of her body. Her eyes were also having convergence spasms every few seconds, which explained why she was feeling so dizzy.
Personalized, continuously adapted treatment
The specificity enabled by the advanced diagnostics at The FNC leads to unique, personalized treatment plans. “We’re not just using generic protocols for dizziness or imbalance and treating everyone in the exact same way,” says Schmoe. “We find the perfect recipe for each person.”
One person may need adjustments to their neck before eye exercises will be helpful. Someone else may need to concentrate on enhancing muscular feedback. One person may need to wear a weighted vest while doing vestibular therapy in the GyroStim chair, while another may not.
“We get very, very specific with each individual person while they’re here. And we have the diagnostic capabilities to see if we’re making a difference, so we can adapt the therapy along the way,” says Schmoe.
Here are some of the primary therapies used at The FNC to treat complex dizziness:
The GyroStim chair is a computerized, multi-axis rotational chair cleared by the FDA for use in vestibular therapy and rehabilitation. It allows for precise control over the speed, direction, and duration of rotations, mimicking a wide range of motion scenarios that the vestibular system might encounter in daily life.
“You’re using your eyes, neck, muscles, visual system, and vestibular system at the same time, helping the nervous system to integrate and make sense of all of those different systems,” Schmoe says. Doing active movement while being passively moved helps the brain recalibrate and figure out where it is in space.
This can be done with fine-tuned, specific movements based on diagnostic test results. People are never flipped around in a way that will make them distressed or uncomfortable.
By exposing the brain to various rotational movements, the GyroStim can help promote neuroplasticity, encouraging the brain to adapt and improve its processing of vestibular information. For patients with motion sensitivity, it can help gradually desensitize the vestibular system to movements that typically trigger symptoms.
Virtual reality (VR) is another therapeutic tool that’s highly useful for treating complex dizziness and vertigo. It offers a controlled, immersive environment where patients can be gradually exposed to situations that trigger their symptoms, such as busy streets, moving vehicles, or heights. This can help desensitize the vestibular system, making real-world experiences less overwhelming.
VR can also be used to practice gaze stabilization exercises, where patients focus on a fixed point while moving their heads. This helps improve the vestibulo-ocular reflex (VOR), reducing symptoms like dizziness and disorientation. VR environments can simulate various surfaces and movements, helping to improve balance and coordination.
VR integrates visual, auditory, and proprioceptive cues, helping patients retrain their brains to process and integrate sensory information more effectively. This is particularly useful for patients whose dizziness is triggered by sensory mismatches, such as visually complex environments.
Calming the limbic system is often an important facet of treatment for complex dizziness as well. Whether through connecting with mental health providers in our referral network, using a vibroacoustic sound bed, electrically stimulating the vagus nerve, or empowering patients with information and insight into the underlying causes of their symptoms, proactive steps can help start to unwind the feedback loop between a stressed limbic system and symptoms of dizziness.
Caitlyn’s first day of treatment at The FNC involved some gentle introductory therapies. “They did some cranial sacral head holding and body rotation, and we worked with some gaze stabilization that was quite different from the kind that I had mastered in vision therapy,” she says. “They used a facial nerve stimulator to access my vagus nerve, which has a lot to do with control of the autonomic nervous system—breathing, heart rate, and all things stress or calm. I felt immediately calmer, and they could see differences in my gait and posture.”
As treatment continued, the team worked on her eye movements, with a focus on dynamic rather than stationary exercises. They started by moving her body for her, ensuring that incorrect posture and movements didn’t reinforce her dizziness. During her first week of treatment, they focused on rebooting her vestibular and balance system, including gaze stability and aligning her posture. Exercises included squatting, lunging, and games to improve her timing, which immediately reduced her dizziness.
Following the intensive portion of her treatment, Caitlyn continued practicing a personalized vestibular-ocular therapy routine three times a day. She has noticed significant improvements: her anxiety has lessened and her heart rate has stabilized. Dizziness in daily tasks has greatly diminished, and she’s sleeping better.
“I feel more grounded in my body than I have ever been. I actually have an embodied sense of what that word ‘grounded’ means now,” she says.
Each person’s path to recovery from complex dizziness and vertigo is unique. Even when it doesn’t resolve 100%, it’s often possible to see significant improvements that greatly enhance overall quality of life.
Schedule a consultation today to discuss how we can help.
