What is a vestibular disorder?

Injury or damage to the vestibular system might affect the sensory information responsible for balance and eye movements. Vestibular disorders can be central such as Multiple sclerosis or peripheral. Sensory information about the balance and positioning of the body is partly relayed to the brain from the inner ear. Disruption in the inner ear portion of the pathway of sensory information being relayed to the brain is called a peripheral vestibular disorder.  If affected balance is due to damage of a structure within the brain itself (that affects the reception and integration of balance information), it is called a central vestibular disorder.

The most common peripheral vestibular disorders that are treated by vestibular rehabilitation therapy (VRT) are: benign paroxysmal positional vertigo (BPPV), and injuries, which cause inner ear dysfunction such as Ménière’s disease, acoustic neuroma, and vestibular labyrinthitis or neuritis.  Lowered vestibular function may be unilateral (in one ear) or bilateral (both ears). The effectiveness of the treatment will depend on the exact cause of the vestibular issues.

• nausea
• cold sweats
• ringing in the ears (tinnitus)
• Impaired hearing
• twitching eyes
• ear fullness/pressure
• Impaired balance, increased risk of falls & falls

What is Vestibular Rehabilitation Therapy?

Vestibular rehabilitation therapy (VRT) is a specialized exercise-based program encourages the brain and spinal cord to make up for balance or equilibrium deficits, which are caused by inner ear or central nervous system disease or abnormality.
VRT is used for treatment of vestibular disorders such as vertigo and dizziness, gaze instability, and in some cases loss of balance or falls. Other problems can also arise that are secondary to vestibular disorders, such as nausea and/or vomiting, reduced ability to focus or concentrate, and fatigue.

Symptoms due to vestibular disorders can affect the quality of life and can lead to emotional problems such as anxiety and depression, a sedentary lifestyle to avoid worsening of the symptoms such as dizziness or imbalance, and deconditioning as a result. Treatment strategies used in rehabilitation can target these secondary problems.

The goal of VRT is to use a series of customized exercises to address each person’s specific problem(s). A comprehensive clinical examination is required to identify problems related to the vestibular disorder before an exercise program can be designed, Depending on the patient’s needs, the components of the exercise program can include: habituation, gaze stabilization, balance training. Central vestibular disorders might improve with VRT. However, VRT is found to be more effective in the treatment of peripheral vestibular disorders.

Symptoms of dizziness that are provoked by self-motion or visual stimuli can be treated by habituation exercises. Examples of self-motion are quick head movements, or change positions like bending over or looking. Visual stimuli happens in environments such as shopping malls and grocery stores, when watching action movies or sports on T.V., and/or walking over patterned surfaces or shiny floors. Habituation exercise is not suited for dizziness symptoms that are spontaneous in nature and do not worsen because of head motion or visual stimuli. In habituation exercise the patient is exposed to the repeated same movements or visual stimuli that provoke dizziness. These exercises temporarily increase the symptoms. With continued treatment the intensity of the patient’s dizziness will decrease as the brain learns to ignore the abnormal signals it is receiving from the inner ear.

Gaze Stabilization exercises improve the coordination between eye movements and during head movement. These exercises are used in patients who have problems seeing clearly when moving about. The patient might feel that their visual world is bouncing around when reading or trying to identify objects in the environment. Your physiotherapist with design exercises to use vision and body sense as substitutes for the damaged vestibular system.

Balance training exercises should be designed to address each patient’s specific underlying balance problem(s).  Also, the exercises need to be both safe and moderately challenging. Your physiotherapist will use visual and somatosensory cues, stationary positions or dynamic movements, coordinated movement strategies, dual tasks. Balance exercises can be aimed to reduce environmental barriers and fall risk during more demanding activities like running, so that patients can safely and confidently return to their daily activities.

What can I expect from Vestibular Rehabilitation Therapy?

First, a comprehensive clinical assessment will be performed in order to collect a detailed history of the patient’s symptoms and their impact on person’s daily activities. Information hearing, vision or balance problems, medical history, medications, previous and current activity level, and the patient’s living situation will be collected. The therapist will test the visual and vestibular systems, sensation, muscle strength, extremity and spine range of motion, coordination, posture, balance, and gait.

From the findings of the clinical assessment, laboratory and imaging studies, and patients’ goals for rehabilitation a specific exercise program will be designed. The focus of the program is different in a person with BPPV vs. someone with gaze instability or with balance problems. Exercises can be performed regularly at home. Compliance with the home exercise program is essential to help achieve rehabilitation and patient goals. Therefore, patient and caregiver education is an integral part of VRT.

It is useful for the patient to understand the pathology behind the vestibular problems, and how they arise difficulties they experience with their daily life. A therapist can also educate patients how to deal with these difficulties.

How long does it take to learn Vestibular Rehabilitation Exercises?

VRT exercises are not difficult to learn, but to achieve maximum success patients must commit to perform them on a regular basis as the physiotherapist advises. It is important to set up a regular schedule to incorporate the exercises into daily life. Like many other treatments, symptoms might worsen in the beginning. However, with continuation and persistence symptoms steadily decrease, and difficulties arisen from vestibular symptoms will improve. Your physiotherapist will revise and advance exercise program as symptoms improve.

What factors affect recovery?

The type of vestibular disorder affects recovery. Patients with stable vestibular disorder such as vestibular neuritis or labyrinthitis, have a better chance for faster recovery, whereas in people with progressive vestibular disorder, e.g. multiple sclerosis, migraine, or Meniere’s disease success with VRT is more difficult. In these cases medication, diet, behavioural treatment help reduce the symptoms.

VRT is more successful in patients with unilateral lesion as compared to those with bilateral lesions. In central vestibular disorders the structures of the brain are affected which makes the success of VRT more difficult.

Other factors that might delay recovery include: bodily pain, sedentary lifestyle, certain and/or multiple medications, the presence of other medical conditions, and emotional concerns such as depression and anxiety.

What are the most commonly diagnosed vestibular disorders?

The most commonly diagnosed vestibular disorders include BPPV, Ménière’s disease, labyrinthitis or vestibular neuritis. Other conditions include complications from aging, autoimmune disorders, and allergies.

1. Benign Paroxysmal Positional Vertigo (BPPV)

Benign paroxysmal positional vertigo (BPPV) is the most common vestibular disorder. It is characterized by recurrent short vertigo spells (usually 10-60 seconds) and is most often triggered by certain head positions. It is a benign, which means non-life threatening. Paroxysmal means it has a rapid and sudden onset of the symptoms. BPPV is mostly one-sided; it can occur at any age but more common in women and people over the age of 60.

BPPV occurs when calcium carbonate crystals within the semicircular canals of the inner ear dislodge their location in the vestibular system and migrate into one of the semicircular canals of the inner ear. The cause of BBPV has not been known; however, some risk factors include: head injury, ear surgery, ear infection, and natural degeneration of structures in the inner ear.

The crystals settle in one spot in the canal when the head is still.  It is with the head movement that the crystals move and trigger nerves in the semicircular canal resulting in the sensation of spinning, and if severe, nausea and involuntary eye movements (known as nystagmus). The vertigo usually lasts less than 60 seconds and will settle if the provoking position is maintained.

Sudden changes in head position that provoke the vertigo include looking up ward, looking down, getting out of bed, bending over, lying down quickly and rolling over in bed.

2. Meniere’s Disease

Meniere’s disease is a chronic incurable vestibular disorder with symptoms of episodic severe vertigo, fluctuating hearing loss, ear ‘fullness’ and/or ringing in the ear (tinnitus), and nystagmus. Other symptoms include anxiety, diarrhea, trembling, blurry vision, nausea and vomiting, cold sweats, and a rapid pulse or heart palpitations.  Following the attacks patients often feel extreme tiredness, which requires many hours of rest to recover.

The exact cause of Meniere’s disease is unknown; however, it is postulated that an abnormal amount of endolymph fluid and/or potassium build up in the inner ear are related to Meniere’s disease.

Acute Meniere’s attacks might take between 20 minutes to 24 hours. The attacks can be frequent or apart from week/s or months.  For some patients time between attacks may be symptom free but other patients report ongoing related symptoms even between attacks.

3. Vestibular Labyrinthitis or Neuronitis

Vestibular labyrinthitis or neuronitis is an inflammation of the inner ear or its nerves. The inflammation of the vestibulocochlear nerve causes vertigo, and in some cases leads to hearing impairment. Other general symptoms of vestibular disorder such as nausea, loss of balance, and etc. are also common in vestibular labyrinthitis. The cause of infection in most cases is viral as compared to bacterial. Proper assessment and examination is required to diagnose the type of infection in order to plan the most effective treatment methods.

4. Acoustic Neuroma

An acoustic neuroma is a non-cancerous tumour on the vestibulocochlear nerve. In the beginning, symptoms include impaired hearing on affected side, ringing in the ear, feeling of fullness in the ear, and dizziness. As the tumour grows, it might start to push on other structures and nerves in the area that in turn might lead to symptoms such as pain and numbness in the face, pain, impaired balance, headaches and vertigo.

What are vestibular rehabilitation exercises?

After proper evaluation and diagnosis of the symptoms through a series clinical examination your physiotherapist will plan and administer a customized treatment protocol for your specific needs.  A proper evaluation includes a subjective history, an eye movement assessment, a vertigo assessment, a balance and gait assessment, and observing for compensatory strategies.

The treatment involves a progressive series of exercise programs aimed to train the brain and spinal cord to make up for any balance or equilibrium deficits caused by vestibular disorder. The basis of the exercise program is to adapt and adjust to the stimuli and develop other sensory pathways to be able to have normal function. You will be performing some exercises in the clinic under the supervision of your physiotherapist. Your physiotherapist will teach you some exercises to perform at home. The exercises include:

1. Adaptation Exercises

These exercises are aimed to improve the vestibular system ability to adapt to head movement by movement of images across the retina. The most common program is Cawthorne-Cooksey Exercises.  These exercises progress from eye and head movements in sitting, standing, and combined with other vestibular tasks.

2. Substitution Exercises

These exercise use use visual cues and signals from joints and muscles to improve gaze stability and postural stability that can compensate for the loss of vestibular sensory signals.

Gaze stability exercises improve one’s vision while the head is moving. For example, a patient may be asked to focus on a target, keep it in focus, and then move their head side to side, all the while maintaining focus of the target. Specific exercises, which vary the speed of the head motion and the position of the head, such as those done when lying, sitting or walking, will also need to be trained.

An example of an exercise that challenges postural stability would be one where you are standing on a soft mat and trying to balance.  To advance this exercise, the exercise would first be done with eyes open and then eyes closed.

3. Habituation Exercises

These exercises stimulate the symptoms and works to fatigue the vestibular response to the stimuli such that the symptoms decrease and improve over time.  For example, the patient will be asked to repeat the movement that provoke the dizziness and rest between repetitions such that the symptoms settle. The patient repeats the exercise several times a day. It is expected that the severity and length of the symptoms improve over time.

4. Compensation Exercises

These exercises use the vision and somatosensory cues (other systems responsible for balance) with vestibular cues to improve to counteract the affected vestibular system and enhance balance and gaze stability. Your physiotherapist will design exercises and teach you strategies that help you manage the symptoms.

5. Canalith-Repositioning Manoeuvre or Exercises

These exercises are used in the treatment of BPPV. Common manoeuvres used to treat BBPV are Epley Manoeuvre and the Semont Manoeuvre (Liberatory manoeuvre.) Both manoeuvres need to be performed y a physiotherapist. In most cases one treatment is enough to treat the BBPV symptoms.

6. Machine-based Exercises

Virtual-reality simulators and moveable standing platforms are used to treat symptoms of vestibular disorders. The pros of using technology are having an objective measure of symptoms and their change over the course of rehabilitation.  Furthermore, they improve learning ability by providing feedback and visual cues.

7. Gait Training

These types of exercises work specifically on how you walk. Many people with vestibular issues develop an inefficient gait pattern. Your physiotherapist will assess your walking pattern and will prescribe specific exercises to address any issues you may have developed to compensate for your vestibular symptoms.

8. General Body Exercise

General body exercise has been found to improve general and overall sense of well-being. Your physiotherapist will advise you to start with gentle activities such as walking on even, flat terrain to more challenging environments.

9. Education

Your physiotherapist will educate you about the management of symptoms and how to prevent secondary injuries such as falls due to vestibular disorder.