Dizziness, vertigo, and disequilibrium are some of the most common symptoms reported by adults during their doctors’ visits. They are symptoms that can result from vestibular disorder—either peripheral vestibular disorder (a dysfunction of the balance organs of the inner ear) or central vestibular disorder (a dysfunction of one or more parts of the central nervous system that help process balance and spatial information).
Symptoms due to vestibular disorders can diminish quality of life and impact all aspects of daily living. They also contribute to emotional problems such as anxiety and depression. In addition, people with vestibular disorder tend to be more sedentary in order to avoid bringing on, or worsening, dizziness and imbalance. As a result, increased joint stiffness, reduced stamina, and decreased muscle strength and flexibility can occur.
Those three symptoms—dizziness, vertigo, and disequilibrium—can be linked by a common cause; however, each has different meaning. Dizziness is a sensation of lightheadedness, faintness, or unsteadiness. Vertigo has a rotational, spinning component, even when a person is completely still. “Disequilibrium” simply means “unsteadiness or imbalance.”
Contents
Balance Mechanisms of Our Bodies
Three systems that maintain our balance are as follows:
- Vision
- Proprioception (touch sensors in the feet, trunk, and spine)
- Vestibular system (inner ear)
The brain stem integrates and processes sensory input from these three systems. In response, the eyes receive feedback messages to help maintain steady vision, and the muscles receive feedback messages to help maintain posture and balance.
In those three systems, the vestibular system is the most important system for balance and supplies the most reliable information about spatial orientation. Mixed signals from vison or proprioception can usually be tolerated; however, vestibular-system abnormalities are more problematic for our balance. Sensory conflicts due to vestibular-system malfunctions result in symptoms such as dizziness, vertigo, and disequilibrium.
Anatomy of the Ear and Vestibular System (Inner Ear)
The ear is divided into three main parts: the outer ear, the middle ear, and the inner ear. The inner ear is filled with fluid.
The role of the outer and middle ear is to transmit sound to the inner ear (vestibular system).
At the inner ear, sound waves are converted into nerve-action potentials. In addition, the inner ear is also responsible for the sense of equilibrium, which relates to our general abilities for balance and coordination.
Causes of Vestibular Dysfunction
Most common causes
- Head injury
- Aging
- Viral infection
Other possible causes
- Illnesses
- Genetic and environmental factors
Some of the dizziness caused by vestibular (inner ear) dysfunction includes:
Acoustic neuroma
Autoimmune inner ear disease
Benign paroxysmal positional vertigo (BPPV)
Cervicogenic dizziness
Cholesteatoma
Enlarged vestibular aqueduct
Labyrinthitis and vestibular neuritis
Treatment for Vertigo, Imbalance, and Dizziness due to Vestibular Dysfunction
The form of treatment for vestibular disorders depends upon symptoms, medical history, general health, a physical examination by a qualified doctor, and diagnostic test results. In addition to addressing any underlying disease that may be contributing to the balance disorder, treatment can include:
Vestibular rehabilitation therapy (VRT)
Canalith repositioning maneuvers
(e.g., the Epley maneuver)
Home-based exercise
Dietary adjustments
Counseling
Medication
Surgery
How Physical Therapists Can Help with Vestibular-System Dysfunction
Vestibular rehabilitation therapy (VRT)
According to the evidence 1,2, vestibular rehabilitation therapy (VRT) can be effective in improving symptoms of many vestibular (inner ear/balance) disorders. VRT aims to address vertigo, dizziness, visual disturbance, and/or imbalance experienced by people with vestibular disorders.
What is VRT?
It is an exercised-based program primarily designed to reduce vertigo, dizziness, gaze instability, and/or imbalance and falls. The goal of VRT involves using a problem-oriented approach to promote compensation of the brain’s sensory system. VRT uses exercises that are customized to address each person’s specific problem(s). Therefore, a comprehensive clinical examination is needed to identify problems related to the vestibular disorder in order to design an exercise program.
Three principal VRT methods can be prescribed depending on the identified vestibular-related problem(s):
- Habituation
- Gaze stabilization
- Balance training
Habituation Exercises
This is a treatment method used to treat symptoms of dizziness that are produced because of:
- Self-motion
Dizziness with movement, such as quick head movements, or with changing positions (like bending over or looking up to reach above the heads)
- Visual stimuli
Dizziness in visually stimulating environments, like shopping malls, grocery stores, watching action movies or TV, and/or walking over patterned surfaces or shiny floors
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- Spontaneous dizziness
- Dizziness which does not worsen with head motion or visual stimuliHabituation exercise is not suited for:
The goal of habituation exercise is to reduce the dizziness through repeated exposure to specific movements or visual stimuli that provoke patients’ dizziness. These exercises are designed to mildly—or at the most, moderately—provoke the patients’ symptoms of dizziness. The increase in symptoms should only be temporary, and most importantly, the symptoms should return completely to the baseline level before patients continue on to other exercises or tasks. When exercises are done over time and with good compliance, the brain learns to ignore the abnormal signals that are received from the inner ear, and the intensity of the patient’s dizziness will decrease.
- Gaze-Stabilization Exercises
These exercises are appropriate for:
- Patients who report problems seeing clearly because their visual world appears to bounce or jump around
This type of exercises is used to improve control of eye movements so that vision can be clear during head movement.
Procedures of Gaze-Stabilization Exercises:
Begin with simpler exercises; progress to harder ones.
These exercises incorporate many “dimensions”: speed/frequency, target, distance (near/far), background, orientation of head on trunk, etc.
- Balance-Training Exercises
These exercises are used to improve steadiness in order to enhance success and safety in daily activities, such as self-care, work, and leisure. These exercises have to be specific to each individual’s underlying balance problem(s) after thorough examination.
Some examples of exercise include:
- Visual and/or somatosensory cues
- Stationary positions and dynamic movements
- Coordinated-movement strategies (movements from ankles, hips, or a combination of both)
- Dual tasks (performing a task while balancing)
- McDonnell, M. N., Hillier, S. L. “Vestibular Rehabilitation for Unilateral Peripheral Vestibular Dysfunction.” Cochrane Databases of Systematic Reviews 2015, Issue 1. Art. No.: CD00397. DOI: 10.1002/14651858.CD005397.pub4
- Herdman, S. J. “Vestibular Rehabilitation.” Curr Opin Neurol; 2013:26:96-101.
The three exercises above are very effective for people who have dizziness due to vestibular dysfunction. However, these exercises do not work, unfortunately, if the dizziness is caused by benign paroxysmal positional vertigo (BPPV).
What is benign paroxysmal positional vertigo (BPPV)?
BPPV is one the types of peripheral vertigo and one of the most common types of vertigo. With it, small crystals or stones found normally within the inner ear can become displaced and cause irritation to the small hair cells within the semicircular canals that sense head motion. When this happens, the inner ear sends false signals to the brain, and this leads to vertigo. Common causes of this are trauma, infection, or even simple aging.
How can a trained physical therapist or other professional use specific training to help a patient with BPPV?
Step I: Testing of BPPV with Dix-Hallpike test
The Dix-Hallpike test is a diagnostic maneuver used to identify BPPV.
Step II: Treatment with a specific maneuver
Canalith repositioning procedure (CRP)
- Epley maneuver: a maneuver used to treat BPPV of the posterior or anterior canals.
CRP is very effective, with an approximate cure rate of 80%. The recurrence rate for BPPV after these maneuvers is low.
Home-Based Exercise
During vestibular-rehabilitation therapy, home exercises are a vital part of treatment. If they are done only when patients see the therapists (usually once or twice a week), it is not enough. They have to be done every day. A physical therapist or occupational therapist specialist will design an individualized treatment plan with appropriate exercises to be performed at home.
Living with a Vestibular Disorder
Living with a vestibular disorder can affect a person’s life in many ways. It can affect not only how you feel, but also how you are able to perform day-to-day activities. With or without a diagnosis, many people need guidance about how to self-educate and self-care to overcome the daily challenges. You are not alone! Many people have contacted therapists at BeWell Home Physical Therapy asking for help. Please feel free to contact us directly.
Doctors: Many people have contacted therapists at BeWell Home Physical Therapy asking for help. If you have any patients who you think will benefit from our therapy care, please let them know.
