The simple act of keeping our balance requires an interaction between our eyes, inner ears, nerves, muscles, joints and our brains. We must be able to accurately sense how we are positioned in space and we need to be able to move our bodies quickly enough and with enough force to correct any imbalance our senses inform us of. A problem at any point in this complex chain can result in a potentially dangerous loss of balance or in feelings of dizziness or vertigo.

Vestibular and Balance Rehabilitation involves the use of the Physiotherapy modalities of exercise and facilitated body movements to treat dizziness and vertigo or problems with balance. Because there are many different causes of these problems, a specialized evaluation is required to determine which of a variety of different treatments is the right choice. The majority of people suffering with vestibular problems have been found to benefit from Vestibular Rehabilitation. In the case of the most common vestibular disease, benign paroxysmal positional vertigo (BPPV), 80% of people need only a single treatment to get better. Vestibular Rehabilitation can often help even in these those cases where medical testing has failed to find the exact source of the problem.

Vestibular Rehabilitation (Dizziness and Vertigo)

What is the vestibular system?

Your vestibular system consists of the parts of your inner ear and brain that are responsible for keeping your balance. When these body parts become damaged or irritated, the result can be vertigo or dizziness. Vertigo is an intense sensation of spinning, sometimes associated with seeing the world spinning around you. Dizziness is harder to define: some people may experience it as a feeling of spinning or swaying, others may feel it as light-headedness or “fogginess”. Sometimes the two occur together, sometimes they occur on their own. Some people have problems with their balance as well as dizziness and vertigo. If this is the case your therapist will treat you with balance therapy as well as vestibular rehabilitation.

What is vestibular rehabilitation?

Vestibular rehabilitation is the use of the Physiotherapy modalities of exercise and facilitated movements of the body to treat dizziness and vertigo. There are several different causes of vertigo and dizziness, and therefore different treatments are required. The most important step in treating dizziness through vestibular rehabilitation is that of having your doctor or therapist perform a thorough functional vestibular evaluation to identify what part of your vestibular system is involved in causing your symptoms, or if the problem is not a vestibular one at all.

Who can benefit from vestibular rehabilitation?

Anyone who is experiencing dizziness or vertigo can benefit from a vestibular rehabilitation evaluation and a trial of treatment. Most often symptoms of vertigo or dizziness can be eliminated or significantly reduced. Unfortunately, the benefits of vestibular rehabilitation may not be widely known by many physicians. You may have been told that your problem will “go away on its own”. This is sometimes true, but few of us would want to wait several weeks or longer suffering with constant dizziness or worrying about the next attack of vertigo when vestibular rehabilitation might help the problem much more quickly. You may have been told that “nothing can be done”, you have to “live with it”, however, the best available scientific evidence indicates that vestibular rehabilitation is an extremely effective method for helping people with dizziness and vertigo.

What conditions can be treated? / What are the different types of vertigo?

A few of the more typical diagnoses and their treatments are listed below:

BPPV (Benign Paroxysmal Positional Vertigo): BPPV is the most common cause of vertigo. In BPPV, small crystals that have a job to do in one part of the inner ear (called the otolith) make their way into the wrong part of the ear (called the semicircular canals, there are three in each ear). We don’t know why it happens but it is more likely to happen after a bump to the head and it is more likely to happen as we get older. This causes very intense vertigo lasting from a few seconds to a couple of minutes, most commonly when you look up or down or when you get in and out of bed. It is sometimes accompanied by a constant feeling of less intense dizziness or light-headedness. Treatment consists of helping you take your head and body through a specific set of movements that remove the crystals from where they don’t belong. The good news is that this is the easiest type of vertigo to treat with 80% of people getting better after one treatment and over 90% getting better with two treatments.

Vestibular Hypofunction: Vestibular hypofunction is what happens when one or both of your inner ears become damaged. Several of the conditions described below can result in vestibular hypofunction. Normally, even when you remain perfectly still, the vestibular portion of your inner ears is sending signals to your brain. Your brain is used to “listening” to two ears that are equally strong. When the signal from one side is weaker than the other, your brain does not know how to interpret this information and the result can be the sensation of vertigo or dizziness.

Labyrinthitis/ Vestibular Neuronitis: Labyrinthitis and Vestibular Neuronitis are two different kinds of infection of the inner ear. In severe cases, symptoms may begin with constant intense vertigo lasting for more than a day. It is not uncommon for people in this circumstance to be sent to the hospital by their doctor to make sure that the vertigo is not being caused by something more serious like a stroke. The infection can cause damage resulting in a vestibular hypofunction that may be temporary or permanent. Afterwards you can have lasting dizziness or short bursts of vertigo when you move your head. Vestibular rehabilitation cannot fight the infection or repair the damage, but the resulting vestibular hypofunction can be treated.

Acoustic Neuroma: An acoustic neuroma is a benign (non-cancerous) tumor on the nerve that goes from the ear to the brain. This condition must be monitored by a doctor who will determine if and when it requires surgery. The tumor itself and the side effects of surgery both can impair the ability of the inner ear signals to get to the brain, resulting in dizziness from a vestibular hypofunction. Vestibular rehabilitation will not help treat the tumor itself nor can it repair the damage to the nerve, but the resulting vestibular hypofunction can be treated.

Meniere's Disease: Meniere's Disease causes attacks of constant intense vertigo lasting for hours and hours. Vestibular rehabilitation cannot do anything to stop these attacks. Sometimes after an attack you can have lasting dizziness or short bursts of vertigo when you move your head. This might be due to the disease damaging your vestibular system on one side and causing a vestibular hypofunction or due to your brain becoming hypersensitive to vestibular stimulation, both of which can benefit from vestibular rehabilitation.

Central Vestibular Dysfunction: This refers to damage to the brain, such as from a stroke or a disease like multiple sclerosis, that causes dizziness or vertigo. Similar to the case of vestibular hypofunction, your therapist will identify appropriate exercises to stimulate the brain to learn to adjust to “the new normal” of its damaged state and learn to ignore the signals that it is currently interpreting as dizziness.

Post Concussion Syndrome: Concussion, also called a mild traumatic brain injury, often results in a few weeks of unpleasant sensations such as dizziness, nausea, visual problems, and problems with concentration. Unfortunately, the only way to deal with this is to follow your doctor’s orders and rest. However, if these symptoms continue beyond several weeks, vestibular rehabilitation can be used to desensitize the brain to symptom-provoking stimulation.

Chronic Subjective Dizziness: This is a catch-all term meaning “we don’t know why you feel dizzy all the time”. Some people appear normal on every test modern medicine has to offer and yet they still feel dizzy. One theory is that the vestibular part of the brain might have become “reset” by a mild case of BPPV or Labyrinthitis in the past, so that as the ear returned to normal the brain began to perceive it as abnormal. Another theory is that some people for some reason become “hypersensitive” to stimulation to their vestibular system. When dizziness has been interfering with someone’s life for a long time sometimes anxiety and worrying about the dizziness can contribute to the problem, sometimes not. Whatever the reason, vestibular rehabilitation can often help even in these cases where we don’t know what the cause of the problem is.

Cervicogenic (Neck-muscle-related) Dizziness: Rarely, problems in the neck muscles can be the cause of dizziness. If your therapist suspects that this is the case, you will be given orthopedic treatment in addition to vestibular exercises.

Migrainous Vertigo: There is a relationship between migraine headaches and vertigo that is not fully understood. Some attacks of vertigo, even without a headache, can be caused by migraines. Vestibular rehabilitation may or may not help relieve some of these symptoms. More importantly, if your therapist is able to identify signs of this problem you can speak to your doctor about managing your migraines.

Motion Sickness: People who become nauseous because they are carsick, airsick, or seasick, but have no problems with dizziness have not been found to benefit from vestibular rehabilitation.

Low Blood Pressure/ Low Blood Sugar: People who become dizzy due to low blood pressure or low blood sugar will not benefit from vestibular rehabilitation and should discuss their dizziness with their doctor.

Hearing Loss or Tinnitus (Ringing in the Ears): Vestibular rehabilitation has no effect on hearing.

What can I expect from treatment?

Your treatment will be different depending on what problems are identified. Treatment will usually be 30 once a week or once every two weeks.

As noted above, BPPV is usually the easiest type of vertigo to treat. Your therapist will help you move your head and body through what is called a Canalith Repositioning Maneuver (CRM), sometimes called Epley Maneuver: these are a series of positions, which involve lying down and rolling over, that will help move the small crystals out of the semicircular canal. In some less common and more difficult to treat forms of BPPV, different maneuvers, which involve quick head and body movements or a special way for you to roll over and sleep for one night, might be needed. Research has shown that in 80% of cases a single treatment is all that is required for relief. Rarely, long lasting dizziness, without intense vertigo, may persist for some time. This is treatable with vestibular rehabilitation exercises.

For forms of vertigo and dizziness other than BPPV, the treatment of choice is the performance of vestibular rehabilitation exercises. These are simple exercises, most of which involve eye and head movement for no more than a few minutes, performed a few times a day. In order to be effective, these exercises must cause a brief and mild increase in your dizziness, usually for no more than a few minutes. Vestibular rehabilitation exercises reduce the sensation of dizziness over time by presenting your brain with controlled stimulation from the vestibular system, the visual system, and the body. If you give the brain too little stimulation it will not learn, if you give it too much stimulation you will feel very dizzy and likely ruin the rest of your day. The job of the vestibular rehabilitation specialist is to determine the right type and amount of exercise to stimulate the brain just enough to learn. Often symptoms improve significantly or resolve completely over a few weeks as the brain learns to compensate for whatever problem caused the dizziness in the first place. Visits to your therapist every week or every second week are used to check how your symptoms are improving and to adjust the exercise program to ensure the correct amount of stimulation to the brain. Vestibular rehabilitation for conditions other than BPPV requires active participation in your home exercise program for several minutes, several times a day, every day.

If your therapist finds that you are having balance problems as well as dizziness, you will most likely also be given exercises for Balance Therapy.

Balance Therapy

How do we keep our balance?

In order to maintain our balance we must be able to accurately sense how our bodies are positioned in space and whether or not we are off balance. We use three of our senses to help keep our balance. Vestibular sense from organs in our inner ears tell us which way is up and how our head is moving. Sense of touch and position, especially in our feet and ankles, tell us what the ground is like and how we are leaning. Sense of sight lets us see which way is up.

We also need to be able to move our bodies quickly enough and with enough force to correct any imbalance our senses inform us of. Two body systems work together to keep our balance in this way. Our brain, spinal cord, and nerves process sensations and use reflexes to quickly respond to changes in our body position. Muscles, joints, and bones take the signals from the nerves to move the body to keep our balance.

What causes balance problems?

Problems with any one of the involved body systems can lead to balance problems. This can be the result of a specific disease process such as diabetes damaging the nerves in the feet (peripheral neuropathy), a stroke damaging the brain, or severe arthritis making the joints stiff and the muscles weak. It can also be the result of several minor impairments working together to disrupt your balance. As we age our reflexes slow, our vision and inner ear function fade, our joints stiffen, and our muscles weaken. A decline in our ability to keep our balance is a normal part of the aging process. However, falling or being afraid of falling is not a normal part of aging and should be discussed with your doctor and investigated by a physiotherapist who is experienced with balance therapy.

What is balance therapy?

Balance therapy is a specialized type of physiotherapy designed to challenge, strengthen, and retrain the body systems responsible for maintaining our balance. It involves exercises designed to target those areas of body and brain function. If you were training to run a marathon, you would do better to practice running rather than lifting barbells. If you were training to be a better football player, practicing football would help you achieve your goal more effectively than practicing basketball. For the same reason, general strengthening exercises in physiotherapy are less effective at improving your balance than are exercises which specifically challenge your ability to keep your balance.

Because the exercises which best challenge your balance systems are those exercises which quite literally make you almost lose your balance, safety is of primary concern. It is important to have a skilled and experienced physiotherapist who knows how to guard you from falling while still giving your body and brain the freedom of movement to be challenged by the exercises in order to best benefit from them. The job of the balance therapy specialist is to find the appropriate exercises to best challenge your body and brain, always monitoring your safety and your progress and advancing the difficulty level as your balance improves and those exercises which had been challenging to you before become easier over time.

Who can benefit from balance therapy?

Anyone who is afraid of falling and older people who have had falls should see a balance specialist. Other factors known to be associated with risk of falling include answering “yes” to three or more of the following:

  • I feel my legs are not as strong as I would like

  • I have trouble feeling my feet and/or I have been told by my doctor I have “peripheral neuropathy”

  • I have had a fall in the past six months

  • I sometimes feel dizzy or light-headed when I get up

  • I have problems with walking

  • I think my balance is a problem

  • I wear bifocals or trifocals when walking

  • I am taking four (4) or more medications every day

  • I am more than 65 years old

  • I need help getting dressed, bathing, eating, grooming, getting in and out of bed and/or a chair

  • I have a hard time rising from the toilet

  • I have to go the bathroom often and have problems getting there

Keeping your balance involves so many body systems that sometimes, if a small improvement can be made in just a few of these systems, your overall balance will improve. Even if you have had permanent damage to one of these systems, such as peripheral neuropathy, you can still see improvement in your balance by performing exercises which target the other sensory systems to help your brain learn to use them more effectively.

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