Vestibular rehabilitation is a highly effective specialized treatment aimed to alleviate and resolve symptoms that are caused by disorders related to the inner ear. Vestibular rehabilitation is the most safe an effective treatment for vertigo, dizziness, imbalance, disequilibrium, and motion sensitivity.
The vestibular system (AKA inner ear system) provides us with information about our spatial orientation, balance, equilibrium sensation and visual fixation during head movements. It is estimated that approximately 35% of adults over the age of 40 in the U.S. have experienced some vestibular dysfunction, which corresponds to approximately 69 million people. Vestibular rehabilitation focuses on inner ear disorders and dysfunctions between the sensory, inner ear, and visual systems. Vestibular rehabilitation is most commonly used for:
- Benign Paroxysmal Positional Vertigo (BPPV)
- Vestibular Migraines
- Inner ear infection (Labyrinthitis / Neuritis)
- Ménière’s disease
- Post-concussion Syndrome (PCS)
- Perilymph Fistula
- Mal de Debarquement
Once the disorder/dysfunction is identified, we tailor a specific program that is directed to the needs of each client. The most common treatments include canalith repositioning maneuvers (see BPPV), gaze stabilizations, habituation, and balance re-training. The goals of vestibular rehabilitation are to:
- Eliminate vertigo, aka “room spinning dizziness”
- Resolve the sensation of generalized dizziness
- Restore tolerance for movement and visual stimuli
- Improve gaze instability
- Restore normal balance and prevent falls
- Regain confidence in movement during activities of daily living and recreational activities
Benign Paroxysmal Positional Vertigo (BPPV)
Positional vertigo (BPPV) is the most common vestibular disorder and accounts for approximately 50% of dizziness in older adults. BPPV is a mechanical disorder of the inner ear in which calcium carbonate particles (“crystals”) become dislodged and fall into one or more of the 3 fluid-filled canals in the inner ear. These canals sense head motion and send information to the brain. When particles move inside the inner ear canals they interrupt the normal fluid motion which results in false message to the brain. The consequence is a sense of room spinning or self-spinning vertigo. The vertigo typically last less than 1 minute, although residual dizziness is common following each episode. The inner ear and eyes are strongly connected through various nerve pathways. During an episode of BPPV, the false message from the inner ear to the brain will cause the eyes to either rotate or move in a horizontal direction repeatedly and uncontrollably. This phenomenon is call nystagmus.
BPPV can affect children and adults of any age, but is significantly more common in older adults. The majority of the cases are cause with no apparent reason. However, there is a higher prevalence of BPPV cases after head trauma, inner ear virus, migraines and for people with diabetes and thyroid disorders.
BPPV is diagnosed using special test during a clinical examination. The most common tests are the Dix-Hallpike and Roll tests. In these tests the clinician places the patient in positions that trigger movements of the particles inside the inner ear. The clinician observes the patient’s eye movement to determine the affected side and involved inner ear canal.
The treatment for BPPV is called Canalith Repositioning Maneuvers. During the treatment the clinician moves the patients head and body to essentially relocate the particle in the places where they belong. Canalith Repositioning Maneuvers are highly successful with resolution rate of >80% after one maneuver and >90% after 3 maneuvers. It is safe treatment with two common side effects of nausea and residual dizziness that typically resolve within 24 hours after the treatment (although often people recover faster). Canalith Repositioning Maneuvers are done most often by physical therapist specialized in vestibular rehabilitation and ENTs.
Vestibular Migraines / Migraine Associated Vertigo
Most people associate migraines with severe headaches. However, a large portion of people with migraines often have no accompanying pain and their predominant symptoms are related to the vestibular system.
The exact mechanisms of migraine are not completely understood, but the current consensus is that migraines are caused by a combination of vascular and neurological pathological processes. It is believed that a spreading of electrical signals along the cortex (outer layer of the brain) leads to activation of pain pathways that are located near the vestibular system. This results in vestibular dysfunction during a migraine attack.
Similar to a headache migraine, vestibular migraines can be trigged by multiple factors. Among them are food triggers, hormonal fluctuations, barometric-pressure variations, sleep disturbance, stress, and medications.
Approximately 40% of migraine patients have vestibular symptoms involving disruption in their balance, dizziness, motion sensitivity, vertigo attacks (often accompanied by nausea and vomiting), sensitivity to light, sound sensitivity and tinnitus. In addition, patients with vestibular migraines often report neck pain with associated muscle spasms in the upper cervical spine musculature, confusion, spatial disorientation and anxiety.
The diagnosis of a vestibular migraine is done using a thorough clinical examination, including a detailed interview, vestibular and balance tests, a neurological assessment, an auditory assessment (in case of sound sensitivity or tinnitus), and/or ENT examination. Patients are often seen by vestibular rehabilitation therapists for evaluation and treatment.
It is well known that vestibular migraines must be addressed by a combination of medical management, comprehensive rehabilitation techniques, and lifestyle modifications to offer the most complete and lasting results.
Vestibular rehabilitation has been shown to reduce symptoms and restore function for vestibular-related disorders. The rehabilitation program is tailored to the patient’s specific deficits and needs. For patients with visual-perceptual dysfunction, a rehabilitation program that emphasizes visual acuity is effective. Vestibulo-visual interaction exercises also improve eye tracking abilities. If spatial awareness is altered, exercises emphasizing proprioception and visual perception are helpful. Postural instability and imbalance respond well to balance and gait re-training using balance exercises. In cases where the patient has concomitant BPPV (see explanation on BPPV), performing canalith repositioning maneuvers is effective. In addition, manual therapy and exercises has been shown to be effective in reducing neck pain and headaches due to muscle tension.
Vestibular Neuritis and Labyrinthitis
Vestibular Neuritis and Labyrinthitis are disorders resulting from an infection inside the inner ear. The infection causes inflammation that disrupts the sensory signals from the inner ear to the brain. These faulty messages may cause hearing change, visual disturbance, dizziness, vertigo and/or imbalance. Infections of the inner ear are usually viral rather than bacterial. It is important to understand that these infections are different than “middle” and “outer” ear infections, which are typically bacterial.
Vestibular Neuritis is caused by a viral infection that attacks a branch of the vestibular nerve that transmits information about balance from the inner ear to the brain. Typically, there is a gradual worsening of symptoms in the first 24 hours and the person would likely experience dizziness, vertigo, nausea, vomiting and severe unsteadiness. The symptoms will gradually diminish although often there is a residual unsteadiness, sensitivity to head and body movements, and intermittent dizziness that may last from days to weeks.
Labyrinthitis is also caused by a viral infection in the inner ear, but unlike than Neuritis, Labyrinthitis affects both branches of the vestibule-cochlear nerve. As a result, the person will also experience hearing changes along with dizziness, vertigo, and unsteadiness. The progression of symptoms is similar to Vestibular Neuritis, but the hearing changes may stay unchanged. (*Note: Current research studies recommend immediate administration of steroids to minimize hearing loss.)
Vestibular neuritis and Labyrinthitis are diagnosed clinically using a thorough subjective interview, hearing test, postural and balance test, and special tests of thevestibular system. A common vestibular examination is done using vestibular goggles. Using the goggles, the clinician removes the patient’s visual fixation which allows the clinician to observe the “true” eye motion of the patient. The clinician looks for a specific pattern of repetitive uncontrolled eye movement called nystagmus. Additional common tests are electronystagmography (ENG), videonystagmography (VNG), audiogram, and/or vestibular evoked myogenic potentials (VEMP).
Vestibular rehabilitation is a highly effective treatment for recovery and restoration of function following an inner ear infection. The rehabilitation program is tailored to the patient’s specific deficits and needs. For patients with visual-perceptual dysfunction, a rehabilitation program that emphasizes visual acuity is effective. Vestibulo-visual interaction exercises also improve eye tracking abilities. If spatial awareness is altered, exercises emphasizing proprioception and visual perception are helpful. Postural instability and imbalance respond well to balance and gait re-training using balance exercises. In cases where the patient has concomitant BPPV (see explanation on BPPV), performing canalith repositioning maneuvers is effective.
Meniere’s disease is a chronic disorder of the inner ear that is caused by abnormal fluid (endolymph) collection inside the inner ear. The specific cause of Meniere’s disease is unknown, but theories such as circulation problems, autoimmune response, genetics, and allergies have been suggested. Meniere’s disease can develop at any age, but is most common in adults age 40 to 60. It is estimated that there are approximately 600,000 people in the U.S. who suffer from Meniere’s and additional 50,000 new cases are being diagnosed each year.
Meniere’s disease is characterized by periodic “attacks” that last from minutes to hours. The attacks can occur as frequent as multiples times per week and as infrequent as once every few years. The symptoms vary between patients, but often include severe dizziness, imbalance, vertigo, hearing loss and/or tinnitus. Since the specific reason for developing Meniere’s disease is not yet fully understood, prevention is difficult. However, common triggers for Meniere’s attacks are stress, pressure changes, high caffeine intake, high sodium intake, and fatigue. Identifying the patient’s specific triggers is beneficial to properly manage this disease.
The diagnosis of Meniere’s disease is done primarily using the patient’s report of multiple episodes that are similar in nature and cannot be attributed to other more common vestibular diagnoses (i.e BPPV or migraines). Repeated audiograms may be beneficial in cases where a temporary hearing loss is present.
The first line of treatment for Meniere’s disease consists of diet modifications, vestibular therapy, and medications (primarily diuretics). In severe cases, invasive treatments such as intratympanic gentamicin injection or surgery may be required.
Vestibular rehabilitation is a highly effective treatment for recovery and restoration of function during and following a Meniere’s attack. The rehabilitation program is tailored to the patient’s specific deficits and needs. For patients with visual perceptual dysfunction, a rehabilitation program that emphasizes visual acuity is effective. Vestibulo-visual interaction exercises also improve eye tracking abilities. If spatial awareness is altered, exercises emphasizing proprioception and visual perception are helpful. Postural instability and imbalance respond well to balance and gait re-training using balance exercises. In cases where the patient has concomitant BPPV (see explanation on BPPV), performing canalith repositioning maneuvers is effective.