Physiotherapist Role in Vestibular Dysfunction
Summary of a public talk given at a BC Balance and Dizziness Disorders Society (BADD) meeting at St. Paul’s Hospital in Vancouver on September 21, 2014.
Speakers: Riley Louie and Pauline Martin, physiotherapists with specialized training in treating vestibular disorders. Riley and Pauline work at Neuromotion in Kitsilano.
Benign paroxysmal positional vertigo (BPPV) occurs when tiny crystals from the otolith organs in the inner ear dislodge and end up in the semicircular canals. This affects the fluid dynamics within the semicircular canal. The symptoms are a transient intense spinning sensation — vertigo that lasts 30 seconds or less — with certain head movements or positions such as looking up or turning over in bed (usually worse in one direction).
Acute BPPV can usually be assessed and treated by a physiotherapist trained in vestibular rehabilitation. The physiotherapist can assess which canal the crystals are disrupting by using tests such as the Dix-Hallpike. Treatment involves a series of movements — for example, the Epley maneuver — to move the crystals around the canal and back out to where they belong.
Vestibular rehabilitation for non-BPPV vestibular problems requires several visits to the physiotherapist to establish a daily exercise program. The exercises adapt and habituate the vestibular system to reduce symptoms and improve tolerance to daily activities.
Some conditions can expect a full recovery. Others, such as repetitive Ménière’s disease attacks and central disorders, may eventually plateau. These conditions need ongoing guidance to reduce symptoms and to improve management strategies.
Vestibular rehabilitation physiotherapists also treat, in conjunction or separately, conditions which can also present with vestibular dysfunction. These include stroke, traumatic brain injury, multiple sclerosis (MS), and Parkinson’s disease.
Vestibular rehabilitation includes:
- Learning and practicing strategies to reduce symptoms.
- Doing gaze stabilization exercises to coordinate the vestibulo-ocular reflex (VOR). A properly functioning VOR allows you to keep visual targets in focus even when your head is moving.
- Gradually getting your head used to movement and to visual stimuli.
- Using strategies to reduce symptoms. For example, moving your eyes and head separately to reach a target.
Put simply, the three main systems contributing to our ability to balance are:
- Vestibular — detects head movements relative to gravity
- Proprioceptive — ability to tell where your body and joints are in space
As balance is a complex process, rehabilitation can be varied and approached from many angles. These include:
- Addressing head motion intolerance, gaze stabilization and imbalance.
- Adaptive exercises for VOR and habituation for head movement.
- Proprioceptive balance exercises to reduce dependence on vision.
- Starting from gentle to more intense exercises. The goal is to work up to and around a level of challenge in order to provoke slight symptoms.
To be effective, rehabilitation must be done at a level that is neither too easy nor too difficult.