An estimated 90-million Americans will experience dizziness at least once in their lifetime. By age seventy-five, dizziness and balance disorders are one of the most common reasons for seeking help from a physician. U.S. physicians report a total of more than 5-million dizziness/vertigo visits per year, which is a cost of $1-billion according to the Vestibular Disorders Association.
WHAT IS BALANCE, AND HOW DO WE MAINTAIN IT?
Normal balance is dependent on many factors, including multiple systems of the body, as well as external and environmental factors. The body has three primary sensory systems that work together to create postural stability. With normal brain function, the vestibular system of the inner ear coordinates with the visual system and proprioceptors that sense the position and movement of your body in space. These three systems work together while we perform simple tasks, such as standing and walking, or more complex and dynamic activities, such as yoga or hitting a golf ball accurately.
WHAT HAPPENS TO THE VESTIBULAR SYSTEM (INNER EAR) AS WE AGE?
The inner ear is a complex structure of fluid filled tubes and chambers. Specialized nerve endings inside these structures sense the position and movement of the head and detect the direction of gravity. Signals sent from the nerves of the vestibular system are critically important to the brain’s ability to control balance in standing and walking. They also control movements of the eyes that make it possible to see clearly while moving.
Anatomical studies have shown that the number of nerve cells in the vestibular system decreases after about age 55. Blood flow to the inner ear also decreases with age. When the vestibular system is damaged, an individual may experience dizziness and balance problems. However, the gradual, age-related loss of vestibular nerve endings can result in balance problems without any associated dizziness. This type of slow loss of vestibular function may be first noticed as difficulty walking or standing, especially in the dark while on soft or uneven surfaces (such as thick carpet or a forest path). A decline in inner ear function may be caused by a number of conditions, including normal aging, benign paroxysmal positional vertigo (BPPV), infection, Meniere’s disease, or diminished blood flow to specialized nerve cells. Additionally, certain medications such as some antibiotics for severe infections and chemotherapy may damage the inner ear, resulting in temporary or permanent hearing loss, impaired balance, and trouble seeing clearly while in motion. Feelings of dizziness, vertigo, imbalance, and disequilibrium may indicate that the inner ear is not functioning correctly.
Benign Paroxysmal Positional Vertigo (BPPV) is the most common vestibular disorder in older adults and causes a sense of true spinning vertigo triggered by a change of position of the head or body. With this condition, the spinning can be triggered by things like tipping your head up or down, quickly rotating your head, bending over, rolling over in bed, or getting in and out of bed. BPPV is a mechanical disorder that occurs when debris, called otoconia, loosen and tumble into the semicircular canals of the inner ear. This event causes false signals to the brain triggering a brief sense of vertigo. The spinning lasts less than a minute and can provoke nausea, vomiting and imbalance.
OTHER DISORDERS OF THE INNER EAR
Labyrinthitis is an infection or inflammation of the inner ear that causes severe vertigo lasting 1-2 days, hearing loss, and severe imbalance that can affect walking. Neuronitis is a similar disorder causing vertigo, but it does not affect hearing. Both can be triggered by an upper respiratory infection, virus or flu, or can occur with no obvious cause.
Meniere’s Disease causes similar symptoms, including periodic episodes of vertigo, dizziness, and hearing loss. It is thought to be a result of an excess amount of fluid, called endolymph, collecting in the inner ear.
HOW CAN I GET RELIEF?
Advanced Physical Therapy Center (APTC) provides a non-invasive program that entails a systematic, individually designed regimen of exercises and activities such as re-positioning maneuvers and gait/balance retraining.
The goal of Vestibular Rehabilitation is to:
- Improve balance and stability during locomotion
- Minimize falls and improve neuromuscular coordination
- Decrease sensations of dizziness
Therapy can be curative, completely relieving the symptoms, or compensatory, assisting the patient to use other systems more effectively to make up for permanent losses of vestibular function. Most of all, it can decrease the anxiety the patient is experiencing due to his or her disorientation.
The goal of VRT is to use a problem-oriented approach to promote compensation. This is achieved by customizing exercises to address each person’s specific problem(s). Therefore, before an exercise program can be designed, a comprehensive clinical examination is needed to identify problems related to the vestibular disorder. The examination includes administering different tests to more objectively evaluate the patient’s problems. The therapist will screen the visual and vestibular systems to observe how well eye movements are being controlled. Testing assesses sensation (which includes gathering information about pain), muscle strength, extremity and spine range of motion, coordination, posture, balance, and walking ability. Depending on the vestibular-related problem(s) identified, three principal methods of exercise can be prescribed: 1) Habituation, 2) Gaze Stabilization, and/or 3) Balance Training.
Habituation exercises are used to treat symptoms of dizziness that are produced because of self-motion and/or produced because of visual stimuli. Habituation exercise is indicated for patients who report increased dizziness when they move around, especially when they make quick head movements, or when they change positions like when they bend over or look up to reach above their heads. Also, habituation exercise is appropriate for patients who report increased dizziness in visually stimulating environments, like shopping malls and grocery stores, when watching action movies or T.V., and/or when 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. 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 before continuing onto other exercises or tasks the symptoms should return completely to the baseline level. Over time and with good compliance and perseverance, 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 are used to improve control of eye movements so vision can be clear during head movement. These exercises are appropriate for patients who report problems seeing clearly because their visual world appears to bounce or jump around, such as when reading or when trying to identify objects in the environment, especially when moving about.
There are two types of eye and head exercises used to promote gaze stability. The choice of which exercise(s) to use depends on the type of vestibular disorder and extent of the disorder. One type of gaze stability exercise incorporates fixating on an object while patients repeatedly move their heads back and forth or up and down for up to a couple of minutes. The other type of gaze stability exercise is designed to use vision and somatosensation (body sense) as substitutes for the damaged vestibular system. Gaze shifting and remembered target exercises use sensory substitution to promote gaze stability. These exercised are particularly helpful for patients with poor to no vestibular function, such as patients with bilateral (both sides) inner ear damage.
Balance Training exercises are used to improve steadiness so that daily activities for self-care, work, and leisure can be performed successfully. Exercises used to improve balance should be designed to address each patient’s specific underlying balance problem(s). Also, the exercises need to be moderately challenging but safe enough so patients do not fall while doing them. Features of the balance exercises that are manipulated to make them challenging, 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)
Additionally, balance exercises should be designed to reduce environmental barriers and fall risk. For example, the exercises should help improve patients’ ability to walk outside on uneven ground or walk in the dark. Ultimately, balance training exercises are designed to help improve standing, bending, reaching, turning, walking, and if required, other more demanding activities like running, so that patients can safely and confidently return to their daily activities.
Stephani Pobocik, PT, DPT performing re-positioning maneuvers on a patient with Benign Paroxysmal Positional Vertigo in our Clio clinic.
For patients with Benign Paroxysmal Positional Vertigo (BPPV) the exercise methods described above are not appropriate. First a clinician needs to identify the type of BPPV the patient is suffering from, and then different re-positioning exercises can be performed.
After BPPV has been successfully treated and spinning symptoms have resolved, some patients will continue to report non-specific dizziness (symptoms other than spinning) and/or imbalance. In these cases, treatment using habituation exercise and/or balance training may be indicated.
An important part of the VRT is to establish an exercise program that can be performed regularly at home. Compliance with the home exercise program is essential to help achieve rehabilitation and patient goals.
Along with exercise, patient and caregiver education is an integral part of VRT. Many patients find it useful to understand the science behind their vestibular problems, as well as how it relates to the difficulties they may have with functioning in everyday life. A therapist can also provide information about how to deal with these difficulties and discuss what can be expected from VRT. Education is important for patients because it takes away much of the mystery of what they are experiencing, which can help reduce anxiety that may occur as a result of their vestibular disorder.
If you are experiencing any of these symptoms, contact your nearest Advanced Physical Therapy Center ask for one of our vestibular rehabilitation specialists.