Treating Vestibular Disorders with Vestibular Rehabilitation Therapy
Vestibular dysfunction refers to an impairment of the structures of the inner ear that affects your balance and spatial orientation. When the vestibular system is not working properly, the brain does not receive correct information about head motion and movement from the vestibular nerves, which can result in dizziness, vertigo, lack of balance, spatial disorientation, and frequent falls. Vestibular dysfunction can be treated with vestibular rehabilitation therapy, which involves manual head maneuvers and progressive exercises to improve gaze and gait instability, reduce head motion-induced dizziness and fall risk, improve fitness, and enhance functional visual skills.
The Vestibular System & Vision
The vestibular system gives you your sense of balance and an awareness of your spatial orientation. It is a sensory system located in the inner ear that coordinates movement with balance. We navigate the physical world thanks to the integration of the vestibular, visual, and proprioceptive (information we receive through muscles and joints) systems. The vestibular system is comprised of the peripheral vestibular organ located in the inner ear, the vestibulocochlear nerve, the central vestibular organ, and the neural connections situated in the brainstem.
The vestibular organs in the inner ear act like sensors that measure head rotation, forward and back and up and down motions, and head tilts. The vestibular nerve connects the inner ear organ to the midbrain and cerebellum towards the posterior of the brain and transmits motion information from the inner ears to the brain for processing. The brain then processes the information from the inner ear as well as information from your vision, joints, muscles, tendons, hearing, and touch. It then sends out nerve impulses to the eyes, trunk, and limbs so that you can react appropriately to movement and maintain balance.
The inner ear has a unique type of sensory hair cell that is responsive to head motion such that when the head rotates, the hair cells move and this triggers the firing rate in the vestibular-cochlear, or inner ear, nerve. The nerve sends this signal to the brain, eye, and postural muscles.
This signal becomes asymmetric if the head rotates to one side, so the firing rate from the right vestibular nerve increases when the head is turned right while the left vestibular nerve decreases, and vice-versa. The difference in the firing rate is interpreted by the brain as a rotation of the head and is used to provide stability to the eyes and postural muscles to maintain balance during head motion. When the signal is sent to the brain from the inner ear and then to the eye, the eye muscles respond by causing our eyes to move in the opposite direction to maintain a stable image on the retina.
The vestibular system and the visual system work together to stabilize our vision and maintain balance through the vestibulo-ocular reflex (VOR), the ear-to-eye connection. The VOR plays a critical role in keeping the eyes still during head motion and sends signals down to the postural muscles of the trunk, arms, and legs to maintain balance.
What are Vestibular Disorders?
Recent studies have estimated that as many as 35% of adults over age 40 experience some form of vestibular dysfunction at some point in their lives and that nearly 85% of dizziness or imbalance issues are due to vestibular dysfunction.
When the vestibular system is not working properly, the brain does not receive correct information about head motion and movement from the vestibular nerves, which can result in a number of symptoms and issues with balance. Common symptoms of a vestibular disorder include dizziness, vertigo (a spinning sensation), nausea and vomiting, fatigue, neck stiffness, headaches, lack of balance, spatial disorientation, cognitive issues, hearing changes, frequent falls, and vision disturbances.
Those with vestibular disorders may experience issues focusing on objects or they might perceive objects moving side to side or revolving around them or that items in their visual field jiggle or bounce during head motion. Other visual symptoms of vestibular dysfunction and VOR impairment include repetitive movement of the eyes, issues with depth perception, coordination, visual acuity, and light sensitivity.
Vestibular dysfunction can be caused by damage to the vestibular system from disease, a viral infection, high doses of certain antibiotics, a stroke, degeneration of the inner ear’s balance function from aging or inactivity, or from a blow to the head, such as a concussion, whiplash, or brain trauma.
Types of vestibular disorders that can cause these symptoms include:
Vestibular neuritis, which involves inflammation of the inner ear structures due to infection like the cold or flu
Vestibular migraine, which involves blood flow changes to the brain that can lead to throbbing head pain triggered by stress, hormones, and weather changes
Meniere’s disease, which involves a periodic, recurrent increase of fluid and pressure in the inner ear that causes damage to the inner ear and can result in loss of hearing or ringing in the ears.
BPPV, or benign paroxysmal positional vertigo, involves mechanical changes in the inner ear that cause periods of spinning sensations when the head is in certain positions. BPPV occurs when small crystals in the inner ear become dislodged and enter the inner ear canals.
Vestibular Rehabilitation Therapy
At Mangiarelli Rehabilitation, our physical therapist Jen specializes in vestibular disorders and vertigo and is trained to provide vestibular rehabilitation therapy (VRT). Vestibular rehabilitation therapy involves manual head maneuvers and progressive exercises to improve gaze and gait instability, reduce head motion-induced dizziness and fall risk, improve fitness, and enhance functional visual skills.
The physical therapist first reviews the patient’s medical and symptom history and performs a visual and vestibular system screen to observe eye movement control and assess sensation, muscle strength, spinal range of motion, neck movement, coordination, posture, and current gait.
When a patient first begins vestibular rehabilitation exercises, symptoms might increase temporarily, which actually means that the patient is doing the exercises correctly and stimulating the vestibular system appropriately. Over time, symptoms will decrease and resolve as your body learns to compensate for vestibular dysfunction through these exercises.
Vestibular rehabilitation therapy (VRT) can involve:
Habituation Exercises: These exercises are used to treat symptoms of dizziness that occur due to head motion like turning the head quickly or bending forward or due to highly visually stimulating environments like grocery stores. The goal is to reduce symptoms through repeated exposure to specific movements or visual stimuli that provoke dizziness. Over time, the intensity of dizziness decreases as the brain learns to ignore the abnormal signals it is receiving from the inner ear system.
Gaze Stabilization Exercises: These exercises are used to improve the control of eye movements and visual steadiness during head movements and are used for those who experience shaking, shifting, jiggling, or movement when walking, reading, or changing position. To improve gaze stability, the therapist will have the patient work on the vestibular-ocular reflex by fixating on an object while repeatedly moving the head back and forth or up and down for several minutes.
Balance Training Exercises: Balance training is used to improve steadiness and the ability to navigate uneven surfaces. Exercises include coordinated movement, completing dual tasks, and changing from stationary to dynamic positions to reduce fall risk. The goal is to improve your ability to stand, bend, turn, and walk while maintaining your balance.
In addition to these three aspects of VRT, the physical therapist may also implement visual targeting and tracking exercises, gait and mobility training, neck stretching and strengthening, core strengthening, multiple stimuli coordination training, postural training, and ergonomic education.
If a patient is experiencing BBPV-induced vertigo, the physical therapist performs repositioning maneuvers to restore the inner ear crystals into place and reduce and eliminate vertigo.
Vestibular disorders can be debilitating and limit your daily activities. Work with a physical therapist today to address your vestibular issues and begin vestibular rehabilitation therapy!
