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Vertigo and Dizziness

Vertigo and Dizziness

Dizziness, headaches and balance problems are common issues that occur as we age or after concussions and whiplash injuries.

Vertigo and other forms of dizziness can have multiple causes, some of which can be successfully diagnosed and treated with physiotherapy.

What to expect at your assessment

We provide a comprehensive assessment and treatment strategies which look for whether the causes is from the:

  1. Neck
  2. Brain i.e. concussion
  3. Inner ear

Your  physiotherapist will do a careful clinical assessment of your head  movements, balance, neck function, nervous system and vestibular system to determine whether your dizziness/ vertigo can be treated with physiotherapy approaches or whether you should have further medical investigation through your physician.

Our approach is to find the best individualized plan for you to help you to decrease dizziness, reduce symptoms and help you restore function as quickly and safely as possible.

Who will benefit?

You may benefit from therapy if you have any of the following symptoms:

  • Dizziness or vertigo
  • Headache
  • Facial pain
  • Nausea
  • vomiting
  • Unsteadiness
  • Loss of concentration
  • Fogginess


Treatment approaches may include:

  • Soft tissue release
  • Joint mobilizations
  • Balance exercises
  • Eye-movement exercises
  • Posture correction
  • Treatment coordination with other health care professionals
  • Home exercise program
  • Education on recovery and activity modification

Diagnoses which may benefit from physiotherapy

Common dizziness issues that can benefit from therapy include, but are not limited to:

  •  BPPV (Benign Paroxysmal Positional Vertigo)
  • Post-concussion Syndrome
  • Cervicogenic Dizziness (related to disorders of the neck)
  • Vestibular Hypofunction / Loss (UVL/UVH)
  • PPPD (Persistent Postural-Perceptual Dizziness)
  • Falls Risk and Balance or Gait Disorders

Service provided by:

Tiffany Shi RPT   (Bio)


More information: 416-925-4687 or email



Vestibular rehab series #1: Can vertigo be treated?










Before we jump into the topic of, can vertigo be treated, let’s clarify one question: Is vertigo the same as dizziness?


Dizziness is often used as an umbrella term to describe a variety of sensations including:

  • light-headedness
  • fogginess
  • unsteadiness
  • room spinning (vertigo)

Vertigo is a specific type of dizziness sensation described as the sense of you spinning or of the room around you spinning.  The term “vertigo” itself is a symptom, the causes/diagnosis for the symptom can vary.

If you’re experiencing vertigo symptom, a physiotherapist who has received training in vestibular rehab can assist you in the diagnosis and treatment of your vertigo.

Why do I get dizzy?

The vestibular system is part of the inner ear. When we change our head position or move our heads, the vestibular system detects the change and helps us to balance, orient ourselves and still be able to see clearly when we’re in motion. Watch the video here

When the system is not working properly, different conditions may develop. One of the conditions may be benign paroxysmal position vertigo, or BPPV.

What is BPPV?

BPPV is the most common cause of vertigo. Out of all the patients seen for vertigo, BPPV accounts for 20-30% of the cases. And the incidence in the general population is ~ 2.5%.

Let’s break the name down a bit more before we go into the details.

  • Benign suggests the condition is not harmful in nature.
  • Paroxysmal means that the symptoms comes and goes.
  • Positional means the symptoms are provoked by position changes of the head, most commonly by looking up, lying down flat quickly, bending forward, and rolling in bed. Each BPPV episode should last no longer than one minute.

If you have had experiences such as “every time I look up to change a light bulb I get vertigo” or “I get vertigo when I quickly lie down on my couch”, keep reading and you’re very likely going to find out how to get your symptoms treated!

What causes BPPV?

Although the exact cause of BPPV still remains unknown, we do see a strong correlation between the onset of BPPV and people who fall into the following categories:

  • over the age of 50
  • experienced head trauma (concussion, car accident)
  • experienced inner ear trauma (ear surgery)

And we have a well-developed explanation for the mechanism behind it!

To understand the mechanism, we first need to understand the anatomy and function of the inner ear. So, let’s take a look at the picture below:

Figure 1. Inner ear anatomy


There are three loopy tubes in our inner ear called semicircular canals (posterior, superior, and horizontal). The tubes are filled with a fluid that has motion sensors in it. These tubes are in charge of detecting rotational head movements (turning head side to side).

The structures next to the 3 tubes, utricle and saccule, contain crystals called otoconia. Those crystals also have motion sensors that detect linear head movements (looking up and down). Normally, when we move our heads, the motion sensors in those structures detect the movement and send signals to our brain, and our brain coordinates our body parts, eyes, and ears accordingly, so we feel steady when we move.

BPPV happens when the crystals are displaced and float into one of the three tubes. The motion sensors in the inner ear are now sending inaccurate signals to the brain, so the brain is coordinating inaccurately as well. It results in vertigo (sense of spinning), nystagmus (repetitive movement of your eyes), and sometimes nausea.

How is vertigo diagnosed?

Vertigo can be diagnosed by a physiotherapist trained in special assessment techniques.  When I see you in the clinic, I will ask you a few questions about the history of your vertigo:

  • Have you had any head or inner ear trauma?
  • Do you experience vertigo when you change your head position (turning in bed, looking up, etc.)?
  • How long does each episode typically last?
  • Does anyone notice that your eyes move repetitively (nystagmus) during the vertigo episode? Such as in this video
  • Do you have a history of neck pain or migraine? (This may indicate there’s something more to your vertigo than BPPV, and I will assess with additional tests and and treat it differently depending on the diagnosis)

During the physical examination, a few special tests will be performed in order to help me understand which tube is involved. During this process, a positive test will reproduce your typical vertigo symptoms.

Once we determine the involved structure, we can go directly into performing a repositioning technique that will put the crystals back. The vertigo usually is resolved within 3 repetitions of the technique. The course of the treatment for BPPV generally takes a few visits.

 Other causes of dizziness

When your symptoms and the findings of the physical examination does not indicate BPPV, we will look into other potential diagnosis such as:

  • Vestibular neuritis
  • Labyrinthitis
  • Migraine associated vertigo
  • Meniere’s disease
  • Etc.

Treatment strategies for those diagnoses are different from those of BPPV, and you can often still benefit from physiotherapy treatments.

Can vertigo be treated?

If you suspect that your vertigo is BPPV, or are unsure of the diagnosis, contact me, Tiffany Shi, Registered Physiotherapist,  at, or simply call us at 416-925-4687 to book a vestibular assessment.


Figure 1:





Tiffany Shi Bio

Tiffany Shi

Registered Physiotherapist, MSc.PT, BSc


Tiffany is a graduate of University of Toronto with a Master of Science in Physical Therapy. Prior to pursuing a career in Physiotherapy, Tiffany obtained a Bachelor of Science degree in Honors Biochemistry from McMaster University.

Tiffany is passionate about helping people to reduce pain, recover from their injury and return to the activities they love. She loves to thoroughly understand the factors contributing to their injury and applies an individual, holistic physical examination which strives to identify the root cause of the condition. Tiffany utilizes education, hands on treatment and different modalities i.e. dry-needling. She combines this approach with evidence-based home exercise programs tailored to her clients’ needs.

Tiffany is a strong believer in life-long learning. Since graduation, she has received her certification in level 1 orthopaedic manual and manipulative physiotherapy, and level 1 functional dry-needling. She has also received advanced training in vestibular rehab to help those who are living with vertigo, dizziness, post-concussion syndrome, or balance deficits. She is training with Maureen Dwight, clinic director of the Orthopaedic Therapy Clinic, in scoliosis rehabilitation. Currently she is studying pelvic floor physiotherapy (non-internal).

In her spare time, Tiffany enjoys fencing, photography, sewing, life drawing, and reading. Tiffany is bilingual, she is happy to provide service in Mandarin if needed.


Can an Inversion Table Help Relieve your Low Back Pain?

I am often asked whether Inversion Tables can help relieve back pain symptoms. You may have seen this treatment in the movies.  It really came into vogue after Richard Gere used Inversion boots in the old movie, American Gigolo.  The concept is that the table tips you upside down and gravity pulls on the weight of your trunk, head and arms.  This stretches your spine to counter the compression created when we are upright. By stretching (“tractioning”) the spine you can reduce the compression on the discs, joints and nerves, with the expectation that back pain can be alleviated.

Although it is a little different in a clinical setting as it is often applied  with a machine on a horizontal table, my early experience with traction was mixed.   At times it was very effective, at others there was no difference and occasionally it could aggravate low back pain. I suspect that if a clinical trial of inversion table treatment was done, you would see similar results.

If you are going to try inversion its important to balance the safety (risk) with the effectiveness, (benefit).  Using an Inversion Table to tip yourself from a slight incline to fully “upside down” is quite unique and unusual for most adults. Although you may benefit from the stretch to the spinal tissues, it can also have negative, potentially harmful effects.

Here are some of the pros and cons of inversion:

Benefits of inversion

  • Relief of low back pain
  • Applying traction type forces to the spine can be helpful in alleviating low back pain symptoms in the short term particularly if done as part of a more comprehensive program of exercise and education.

Risks of inversion

  • Inversion can make your back pain worse. 
  • If the traction-type force created as you suspend yourself “upside down” is excessive you can aggravate the “straight”/extension position of your spine. This may not be tolerated if you have conditions such as spinal stenosis (narrowing of the spinal canal).  You may get more pain if your core muscles are too weak to take the stretch.

Inversion can affect your heart

Another consideration is the effect that tipping will have on other body systems. For example, in the Mayo Clinic newsletter an article on Inversion Tables/Therapy  highlighted the cardiovascular risks if you have a slower heart rate or high blood pressure.  They recommend that if you have a cardiac condition such as an abnormal heart beat or hypertension or if there is a history of stroke or future risk of a stroke that you should not use an inversion table. If you are seeing a cardiologist you should ask what your risks are for this type of treatment.

Other reasons to avoid inversion treatments

  • Any condition where there is increased pressure within the eye i.e. Glaucoma or Retinal disease . Tipping upside down will increase this pressure and put you at risk for damage to the optic nerve.
  • Inner ear problems such as vertigo, dizziness or infections
  • Obesity can be an issue if you have cardiovascular issues as well as from the increased load on your spine and legs
  • Pregnancy
  • Osteoporosis or bone weakening conditions and history of spinal fracture
  • Hernias
  • Taking blood thinning types of medication
  • Gastric issues, such as acid reflux
  • Presence of orthopaedic implants, total hips/total knee replacements

It is strongly recommended that before using an Inversion Table to treat your back pain you discuss any medical issues with your Doctor.  Your physiotherapist can provide you with guidance on whether this is a good treatment option for your back.

The bottom line on inversion tables and low back pain

If you are healthy, with no risk of any of the above conditions, “traction” type forces such as produced by an Inversion Table may be beneficial as part of a more comprehensive program of exercise. A trial of horizontal traction with your therapist can be the first step in deciding if this is the right treatment for you.  If you have back pain and would like to discuss this further or receive other treatment strategies to take control of your pain, please contact me at or 416-925-4687.


Author E. Laskowski MD June 30 2017












Exercise and Concussion

concussionConcussions in both youth and adult populations has been growing exponentially over the past decades. During a 12 months period from 2009 to 2010, Statistics Canada reports that more than 94,000 Canadians aged 12 and older experienced a concussion. Some of this increase may be explained by increased awareness but it also suggests that better prevention strategies are critical.

What is a Concussion?

A concussion is a traumatic brain injury – often classified as a mild traumatic brain injury (mTBI) – that affects the brain’s function. A concussion can be caused by a direct or an indirect blow to the head. Often concussion does NOT involve loss of consciousness. Signs and symptoms of a concussion are generally classified into three categories (Parachute Canada):

A) Physical symptoms include: headache, dizziness, nausea, feeling unsteady, feeling “dinged” or “stunned” or “dazed”, feeling like their “bell was rung”, seeing stars or other visual disturbances, ringing in the ears, double vision, simply “not feeling right”.

Physical signs of concussion include: loss of consciousness or impaired consciousness, poor coordination or balance, easy distractibility and poor concentration, slowness answering questions and following directions, vomiting, looking “glassy eyed”, extreme sensitivity to light (photophobia), slurred speech, personality or behavior changes, and significantly decreased performance or playing ability.

B) Cognitive symptoms include: confusion, amnesia, disorientation, poor concentration, and memory disturbance.

C) Emotional symptoms include: feeling of depression or moodiness.

Post Concussion Syndrome (PCS)

The majority of patients with sport-related concussions recover within 7-10 days and non-athletes recover within the first three months after the injury. After a concussion, some people experience residual physical, cognitive and emotional symptoms. If the symptoms persist for longer than three months, they may be diagnosed with post-concussion syndrome (PCS). This diagnosis requires three or more of the following post-injury symptoms:

  • Headache
  • Dizziness
  • Fatigue
  • Irritability
  • Insomnia
  • Difficulty concentrating
  • Memory difficulties

How does a concussion affect your body?

A concussion not only affects an individual on a cognitive level, it also affects them on a physical level. Concussions can alter heart rate and the autonomic nervous system function, which subconsciously controls important body functions such as breathing and digestion. These changes can mean that someone with a concussion may experience a greater increase in heart rate compared to a healthy individual doing a similar physical activity.

Concussion may cause an unnecessary increase in blood flow to areas of the brain that are not needed during physical cognitive tasks. Healthy individuals have more efficient cerebral blood flow, supplying only the areas of the brain needed for the task. This increase in blood flow in PCS is an indicator that the brain is exerting much more energy and may explain the physical and mental fatigue when performing both exercise and mental tasks after this type of injury.

Guidelines for return to physical activity post-concussion

Too intense of cognitive and physical activity should be avoided immediately after this type of injury as this can increase the severity of the symptoms and lengthen your recovery. In order to safely return to your previous activity level, use these established guidelines to ensure a speedy recovery and to return to your pre-concussion activities. It is important that you are symptom free at each step before you progress onto the next level.

  • Step 1: no activity, only complete rest.
  • Step 2: light aerobic exercise
  • Step 3: sport specific activities.
  • Step 4: begin drills without body contact
  • Step 5: on field practice with body contact
  • Step 6: game play

To assure safety, it is best to consult a physician/therapist before beginning this step-wise return to sport program.

How can Physical Therapy help?

A variety of different types of treatments can be used to help people recover from concussions and PCS. Some of these treatments include; rest, education, neurocognitive rehabilitation, antidepressants and physiotherapy.

When seeing a physiotherapist you can expect a thorough history and physical examination to be completed at the first visit. Your therapist may assess your balance, coordination, cognition, symptoms, and endurance as well as a full neurologic assessment to establish a baseline.  This will help to determine which functions have been affected the most.

Balance and postural stability can be challenged after a concussion as the brain may receive abnormal signals regarding the position and movement of the head in space. Vestibular and balance rehabilitation may reduce dizziness and improve gait and balance deficits if they have not resolved with rest.

You and your physical therapist should establish safe and achievable therapy goals and then design an individualized rehabilitation program to facilitate your post-concussion recovery. There are also an increasing number of studies suggesting a graded aerobic exercise training/intervention program facilitates the healing process. This may help by targeting the physiological dysfunction through increasing parasympathetic (1) activity, reducing sympathetic activation and improving cerebral blood flow. During this type of program your therapist should closely monitor your heart rate, rating of perceived exertion and blood pressure to help progress through the stages of healing while normalizing physiological properties and returning these levels back to the pre-concussion level.

For more information visit Parachute Canada’s After a concussion guidelines for return to play


(1) The sympathetic and parasympathetic nerves regulate the automatic functions of the body i.e. sweating,  These nerves supply organs, blood vessels and glands.

Inversion Tables/Therapy for Spinal Pain

Quite frequently a patient with low back pain will ask about Inversion Tables and whether such equipment can be helpful for treating back pain. The idea of the table is to tip you upside down so that the pull of gravity acting on the weight of your trunk, head and arms stretches the spine to counteract the compression which occurs when we are upright. By stretching the spine in this way (therefore producing a “traction” type force on the vertebral joints) and reducing compression, the expectation is that spinal pain can be alleviated. My experience  earlier in my career with traction applied on a horizontal table was mixed, some patients were relieved, some were no different and occasionally some were worse and I suspect that if  a clinical trial of inversion table treatment was done the results would be mixed also. A key consideration when evaluating any treatment is balancing safety (risk) with efficacy (effectiveness) Applying traction type forces to the spine can be helpful in alleviating symptoms in the short term particularly if done as part of a more comprehensive program of exercise and patient education. What  are the possible risks associated with tipping yourself upside down? Mechanically, the traction type force if excessive might aggravate your pain or the “straight” position of your spine as you are suspended from your feet might not be tolerated by patients with degenerative or stenotic type spines who don’t like to be in extension. The other consideration is the effect that tipping will have on other body systems/tissues. For example, in a recent Mayo Clinic Newsletter ( an article on Inversion Tables/Therapy highlighted the cardiovascular implications of a slower heart rate and higher blood pressure and an increase in eyeball pressure therefore warning against this type of treatment where those medical conditions are present. Another consideration for applying caution might be in cases where dizziness/vertigo are an issue due to inner ear problems. Discussing these medical issues with your health care professional would be a smart thing to do before considering whether this type of equipment is suitable for your condition.

Therapeutic Fitness

Therapeutic Fitness

OTC_tennisTherapeutic Fitness is a new concept in exercise available at The Orthopaedic Therapy Clinic. It combines personal training with the expertise of highly-trained professionals who are experienced in working with individuals with more complex fitness requirements. It is designed for individuals who are recovering from injury, are trying to stay fit while injured or have other conditions that interfere or limit fitness i.e. arthritis. This approach embodies the principles of Exercise is Medicine.

When should I use Therapeutic Fitness?

Therapeutic Fitness is ideally suited for individuals who are working with a physician who has advised you to include exercise in your disease management strategy i.e. high blood pressure. It will also benefit you if you are working with a physical health practitioner such as a physiotherapist, chiropractor or massage therapist as you can maintain or improve your fitness while avoiding strain on the recovering injury i.e. low back pain.

If you are wondering if Therapeutic Fitness is right for you the following 6 questions[1] can help you to decide:

  1. Has your doctor ever said that you have a heart condition OR high blood pressure?
  2. Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?[2]
  3. Have you ever been diagnosed with a chronic medical condition?
  4. Are you currently taking prescribed medications for a chronic medical condition?
  5. Do you have a bone or joint problem that could be made worse by becoming more physically active? [3]
  6. Has your doctor ever said you should only do medically supervised physical activity?

If you have answered yes to any of these questions you should be considering the benefits of  and working with one of our experienced  Therapeutic Fitness exercise professionals.

Who will I see?

At the Orthopaedic Therapy Clinic our Therapeutic Fitness program is provided by Registered Kinesiologists and highly trained fitness professionals.   All therapists have completed a recognized University level course in the science of human movement and its application to improve function, health and performance.

Our Therapeutic Fitness Professionals have training and certifications in physical fitness which forms the foundation for their scientifically based programs. Their training and interdisciplinary commitment helps them to limit inadvertent training side-effects by understanding age-appropriate and condition-appropriate exercise programs. Our team has the knowledge and training to understand when to collaborate with your health professionals.

What can I expect?

At your initial assessment our Therapeutic Fitness Professionals will review your health history to determine if there are any restrictions or concerns for your participation. Depending on your condition and goals they will determine which baseline measures should be monitored i.e. weight, heart rate, blood pressure, oxygen saturation, etc. These measures will help to form the basis for measuring your success as you go forward. They will collaborate with your health team when more information is required prior to formulating a plan to help you meet your fitness and condition management goals.

For more information read Kinesiology services.

[1] Excerpted from the CSEP PARQ+
[2] Answer NO if your dizziness was associated with over-breathing (including during vigorous exercise)
[3] Answer NO if you had a joint problem in the past, that does not limit your current ability to be physically active.