Overview of Vestibular Rehabilitation
Dizziness is a common issue among older adults, with up to 30% of elderly people experiencing it. This problem is seen more often in women than in men. Dizziness can be problematic as it can lead to imbalance and increases the risk of falling. The subsequent consequences like injury, decreased quality of life, and financial costs related to falls can be significant.
In the United States, the problem of an underperforming balance system in the inner ear, known as vestibular hypofunction, is reported by an estimated 35.4% of adults. This issue often results in feelings of dizziness and balance problems. Current studies show promising results when exercise-based rehabilitation is used to treat this condition. This kind of therapy seems to be successful for treating both one-sided (unilateral) and two-sided (bilateral) vestibular hypofunction, as well as problems originating from the central balance system in the brain (central vestibular hypofunction).
Anatomy and Physiology of Vestibular Rehabilitation
The vestibular system is a complex network that includes parts of our inner ear and brain, as well as the eye and muscle systems. This system helps us to keep our balance. Its job is to sense movement of the head, which it uses to keep our posture stable and maintain a steady gaze even when we move our heads.
The vestibular system detects movement using the vestibular apparatus in each ear. This apparatus includes two main parts: otolithic organs (the utricle and saccule) and three semicircular canals. The otolithic organs notice straight-line movement, while the semicircular canals sense rotational or spinning movement. These canals are filled with a fluid called endolymph, and a ‘cupula’ at the end of each canal detects the movement of this fluid.
When we move, this triggers small hair-like cells (stereocilia) in each canal, which then send signals to our brain. Similarly, the otolithic organs use stereocilia to detect motion: the saccule senses up-and-down movement while the utricle picks up side-to-side motion. These nerve signals are sent through the vestibulocochlear nerve to a part of the brain called the vestibular nuclei, where the signals are processed along with other sensory information to help orient us and control our posture.
The vestibular system combines information from our senses of sight and touch as well as from the vestibular system itself. All this information is put together by the central nervous system (CNS), the brain and spinal cord, to give us a complete picture of where we are in relation to our surroundings. If the vestibular system is not working properly (a condition doctors call vestibular hypofunction), it could be due to problems in the peripheral system, the central system, or both, and treatment will depend on the cause of the problem.
Why do People Need Vestibular Rehabilitation
Vestibular rehabilitation, which is a type of therapy for balance problems, is widely recognized as the main treatment for disorders related to the peripheral vestibular system. This is a component of the inner ear and brain that helps control balance and eye movements. Disorders may include benign paroxysmal positional vertigo (BPPV) which causes brief episodes of mild to intense dizziness. For BPPV, they also perform a particular treatment known as canalith repositioning.
Vestibular rehabilitation exercises may also be useful for patients who have a stable condition affecting balance, conditions involving both the central and peripheral balance controls, psychologically induced dizziness, older adults experiencing dizziness, and instances of vertigo, a sensation of feeling off-balance, where the cause is unknown.
Early research shows encouraging results for using vestibular rehabilitation to treat head injuries, particularly concussions, and central disorders such as cerebellar disorders (conditions affecting the cerebellum, a part of the brain that co-ordinates and regulates muscular activity) and Parkinson’s disease, a long-term degenerative disorder of the nervous system that mainly affects the motor system. However, more in-depth research still needs to be conducted to verify the benefits identified in these initial studies.
When a Person Should Avoid Vestibular Rehabilitation
Some conditions can make vestibular rehabilitation therapy, which helps with balance issues, less effective or not suitable. These include unstable problems with the inner ear, or the labyrinth, which controls balance. If the issues with the labyrinth are still ongoing, this therapy often doesn’t help. The same is true for people who have unplanned episodes of dizziness (called vertigo) or issues with balance.
The medications used to reduce dizziness and nausea, depression, and anxiety should not be taken for 48 hours before testing for this therapy. This is because they can interfere with the results. Lastly, some exercises used in the therapy involve moving the neck a lot. So, those with neck problems or blood vessel diseases may not be suitable for these exercises.
Equipment used for Vestibular Rehabilitation
Vestibular rehabilitation, or exercises to improve balance and reduce dizziness, requires little equipment and can be done by a healthcare professional working in any environment. It is important to first fully understand the patient’s medical history, as this helps guide the correct treatment plan. The medical history can be shared by the patient directly, or sometimes by a caregiver. The basic equipment required includes a firm surface like a bed or plinth where the patient can lay for the BPPV (Benign paroxysmal positional vertigo – a condition causing brief episodes of mild to intense dizziness) assessment, and a comfortable chair or surface for the patient to sit on during eye movement, or oculomotor, assessments.
Gaze stabilization exercises, aimed at aiding balance by fixing the gaze on an object while moving, may require equipment to adjust the light and create visually stimulating backgrounds. In the early stages of treatment, a trained professional should be present to ensure balance is maintained effectively and safely. Safety measures, like parallel bars, gait belts or harnesses to prevent falls, must be used. If the patient is deemed safe and capable to perform some exercises at home, they should still ensure to take safety precautions like using a stable surface.
In some cases, a tilting stretcher may be required for patients who need a special maneuver to move crystals in the ear but cannot extend their head. Tools like Frenzel goggles and M glasses may aid in assessing the presence of rapid, uncontrolled eye movements, known as nystagmus, but they are not essential. Caloric testing, which involves warming and cooling the ear canals to test balance function and diagnose issues with a peripheral or central cause, might be useful but would require additional equipment.
It’s crucial to note that additional tests are generally only needed when the diagnosis is unclear, or the patient does not respond adequately to standard treatment.
Who is needed to perform Vestibular Rehabilitation?
Physical therapists are often the ones who guide patients through exercises that aid in the recovery of their sense of balance, a method that is known as vestibular rehabilitation. The ultimate purpose is to have patients return to have a normal day-to-day routine. Sometimes, another specialist known as an occupational therapist, who also knows how to use these balance therapy techniques, can help. This professional can do all the tests and treatments by themselves. However, when treating patients who may be weak due to age or have weight issues, more staff might be needed to ensure safety.
In certain cases, more specialized testing may be needed, or if the problem is due to serious health issues or needs surgery, other doctors will be involved. These could include neurologists (brain experts), otolaryngologists (ear, nose and throat specialists), specialized balance centers, and surgical teams when needed.
Preparing for Vestibular Rehabilitation
Before starting treatment for balance issues (vestibular rehabilitation exercises), it’s important that the patient doesn’t have any health issues that would make the treatment unsafe, and that they agree to the treatment process. Taking off glasses is usually suggested because they can make dizziness feel worse during certain exercises that involve moving the head while focusing on an object.
It can be really helpful to use a questionnaire, chosen based on what the doctor thinks is best, to figure out how everyday activities are being affected. This information can be used to decide what exercises to use. The questionnaire can also help figure out how intense the feelings of dizziness are and how long the symptoms have been happening. This is useful for deciding how to progress with the exercise plan.
How is Vestibular Rehabilitation performed
Vestibular rehabilitation therapy, a treatment method aimed at reducing issues with balance and dizziness, can be helpful for individuals with both peripheral (related to the inner ear, or vestibular system) and central (related to the brain) disorders. Generally, peripheral problems are addressed with exercise-based approaches. Medications may be used to reduce symptoms during the early stages of treatment, but they don’t usually help much in the long run. On the other hand, central disorders, depending on their source, might require ongoing medication treatment.
Issues like difficulty with eye movement and dizziness are common after strokes and concussions. Vestibular rehabilitation has proven to be somewhat effective in these cases, although more research is needed. Patients suffering from multiple sclerosis and Meniere disease have also benefited from these exercises during recovery stages. However, for other types of central disorders, more studies are needed to solidify the results.
To differentiate between peripheral and central disorders, a number of eye-movement assessments can be performed. Patients with central disorders often struggle with fluid eye-movement, changing the focus of their gaze, holding their gaze, and specific types of involuntary eye movement. The Head Impulse Test is a common way of checking the vestibular system, which can help identify peripheral disorders.
Vestibular rehabilitation exercises can be roughly divided into two categories: repositioning exercises for Benign Paroxysmal Positional Vertigo (BPPV) and exercises for vestibular hypofunction, a reduced response of the vestibular system. For checking if a patient has BPPV, there’s a standard test known as the Dix-Hallpike maneuver and a sidelying test, plus techniques for people who can’t tolerate neck extension like the horizontal roll test. These tests are all based on observation of involuntary eye movement and reports of vertigo or dizziness.
The choice of treatment maneuvers depends on the type of BPPV: for canalithiasis, i.e., when the tiny calcium ‘stones’ in the inner ear are floating freely in the canal, the Epley maneuver is used. For cupulolithiasis, when the ‘stones’ are stuck on the bunch of sensitive hair cells in the canal, Semont liberatory maneuver is used. Both methods involve guiding the patient through a series of positions to help move the ‘stones.’
Remember, these treatment techniques are highly specialized and should only be done by a professional therapist. If you experience dizziness or vertigo, it’s best to get in touch with a healthcare provider who can guide you through the right treatment process.
Possible Complications of Vestibular Rehabilitation
When you do exercises for your balance system (vestibular rehabilitation), there are usually very few complications. However, some people might feel nauseous or their symptoms might get worse. Don’t worry, your doctor can make these exercises easier or shorter, and if necessary, they could give you medicine to help with the nausea. In a very rare case, during a procedure to fix certain types of dizziness (canalith repositioning for BPPV), you could get hurt if there are other underlying conditions. That’s why it’s really important to do a full check of your neck and go over your health history with your doctor.
If your balance issue doesn’t get resolved and your body can’t get used to the imbalance (failure to habituate the vestibular system), you might start to move your neck less to avoid movements that trigger dizziness. However, moving your neck less could lead to long-term changes in your neck and overall weakening because you’re not moving around as much overall.
What Else Should I Know About Vestibular Rehabilitation?
Dizziness and balance issues can make you more likely to fall down or feel scared of falling. In fact, dizziness alone costs the US healthcare system roughly $4 billion a year.
Falls are the most common reason why older adults end up in emergency rooms, hospitals, or sadly, even die due to injuries. In 2015, the costs tied to falls was estimated at $754 million, and that number is expected to keep climbing in the next 20 years.
The good news is that there are effective treatments. Canalith repositioning, a procedure that helps to move small crystals in the ear that can cause dizziness, works up to 89% of the time after just one treatment. Also, exercises that help to improve balance (vestibular rehabilitation) are proven to work well for conditions related to an imbalance in your inner ear. This also shows promise as a treatment for some central causes of balance issues. Because of these effective treatments, we should consider their potential to lessen the costs and improve individuals’ quality of life.
