Point out cochlea, semicircular canals, vestibular nerveAbout the size of your pupilVestibular disorders effecting this region are considered “peripheral”, where as some forms of dizziness or imbalance may be due to a “central” problem involving the vestibular nerve entering the brainstem and brain.
Important to understand how normal balance occurs.Vestibular: both sides need to be telling the brain the same thing, otherwise a mismatch signal is perceived by the brain, giving the perception of dizzinessVision: a reflex between the vestibular system and the eye muscles coordinate head motion and visual focus. This is why when we run, the world around us is not jumping all around.Sensation: what we feel in our feet, skin, muscles and joints all give our brains information about where we are in space.
Romberg EO vs EC demo
Depending on the nature of the problem, people with VD can present with difficulty with balance/ steadiness, dizziness with certain position changes, or a sense of motion when either the person is moving, or the world around them is moving.
Visual: blurriness or difficulty focusing with head mov’t—commonly experienced in a busy setting like a supermarket. Reading , watching TV, computer scrollingAuditory: involving loss of hearing, fullness or clogged sensation in the ear, ringing.
This includes testing a patient’s ROM, strength, sensation, balance, eye/head coordination.Reminder: how normal balance occurs.Vestibular: both sides need to be telling the brain the same thing, otherwise a mismatch signal is perceived by the brain, giving the perception of dizzinessVision: a reflex between the vestibular system and the eye muscles coordinate head motion and visual focus. This is why when we run, the world around us is not jumping all around.Sensation: what we feel in our feet, skin, muscles and joints all give our brains information about where we are in space.
Knowing which systems are intact and functioning well, as well as identifying systems that are impaired help direct the treatment.For instance, someone who has vague complaints of dizziness when going from sit to stand and has low blood pressure may have nothing wrong with their vestibular system. They may be better served by monitoring their BP and adjusting their medication as per their physicians’ instructions.Another example of fully understanding the patient’s health is identifying any sensory loss, common in diabetics or other reasons for peripheral neuropathy.
Understanding the anatomy of the vestibular system helps makes sense of why this occurs and why the treatment works.Crystals (otoconia) that are a normal part of the vestibular system’s anatomy, detach and can migrate into one of the 3 semicircular canalsMost common: posterior canal
This diagram demonstrates how certain head positions that stimulate the canal with crystals in it can provoke vertigo symptoms
Symptoms typically last from 5-30 seconds, although it seems like an eternity while its happening!In rare cases it can last for longer than 60 seconds and is treated differently than the short lasting variety of BPPV.
If there are crystals in the canals, this will provoke that spinning sensation.
The treatment starts with the same position as the testing procedure. To further relocate the crystals back to their proper home, the patient is taken through a series of head positions, using gravity and knowledge of anatomy to guides the crystals back to the vestibule. Each position is typically held for 30 seconds and may provoke spinning sensation. The maneuver is repeated 2-3 more times and usually results in less symptoms or they can be completely gone.
After a patient undergoes the Epley maneuver, they are given a few simple instructions to follow, including the Brandt-Daroff exercises to relocate any residual crystals remaining in the canals.This self treatment technique mimics the head position and is similar to the Epley maneuver. Each position is held for 30 seconds or until the dizziness stops. Once you can do these position changes for 2 days in a row without symptoms, you can stop.This is a treatment technique I use for those patients with neck and back issues or general mobility problems.
What seems to help is gaining an understanding of the problem and learning how to manage it. It is probably the most frightening when it first occurs b/c you have no idea why this is happening. Once you recognize the symptoms and learn how it can be treated, most people can go on and live their normal life.
This vestibular disorders arises not from crystals in the wrong location, but from an unequal signal from right and left vestibular systems to the brain. Recall that normal balance occurs from the right and left vestibular systems “saying the same thing” to the brain.
Sometimes the normal aging process can also lead to a vestibular hypofunction.
Patients with a vestibular hypofunction almost always report symptoms of foggy headedness, “not feeling right” in their head, headache, and difficulty focusing, “off balance”.
This is where its so important to listen to the patient! People with a vestibular hypofunction will tell me they can’t tolerate visually busy environments like supermarkets, Target, train stations, airports.They may have difficulty focusing on visual tasks at work, particularly computer work, columns of text to scroll through.They may have difficulty driving, either from quickly turning their head for lane changes, or are bothered by the peripheral visual busyness of the highway.Firm vs foam, EO vs EC demo on Dr. K. This test assesses how well the brain uses vestibular input for orientation when other sensory cues (vision and touch) are not available
Gaze stabilization ex: Start with simple visual targets and progressively more complicated tasks as symptoms allow.Exercises must be done regularly, but in small doses so symptoms do not become too elevated. It is normal, however, for patients to have a mild increase in their symptoms when first starting these exercises.Eventually , exercises should mimic real life situations that are bothersome to the patient, including work related tasks.
Remain active! Change positions frequently. Strengthen the important muscles of balance. Maintain good flexibilitySit to stand, turning and reaching activities, standing on variety of surfaces, EO vs EC.WalkingChair yogaTai chi
Introduce Gina Byrnes, LCSW with our Behavioral Health Department to speak about the anxiety related to Vestibular and Balance Disorders
January 30, 2014
Physical Therapy Evaluation
In order to know which treatment to
prescribe to the patient, the PT must
perform a thorough evaluation to
determine where the symptoms are
Dizziness is a symptom that can manifest
from a vestibular disorder, but can also
• Psychological disorders
Benign Paroxysmal Positional
• Most common vestibular disorder
• 2.4% of all people will experience it at
some point in their lifetime
• 50% of dizziness in people over age 50
When the head moves
sends a false message
• looking up
• rolling over
• getting out of bed.
Test for BPPV
• Hallpike Dix or Roll Test
• Observing for nystagmus and patient
report of spinning
• Guides therapist to know which canal is
affected and, therefore, which treatment
for repositioning to implement
When the vestibular system malfunctions
unresolved sensory conflict
Test for Vestibular
• Oculomotor exam-coordination of eye
and head movement.
• Balance testing with eyes open and
closed, firm/foam surface
• Walking tests involving head movement
Treatment for Vestibular
• Gaze stabilization exercises- to
coordinate eye and head motion
• Habituation exercises- to become more
tolerant of movement
• Standing balance activities
• Walking, fitness and endurance when
Neck Pain and Stiffness
• Common side effect since movement
causes dizziness, therefore patients
tend to avoid head movement.
• PT for heat, soft tissue mobilization,
joint mobilization, stretching,
strengthening, postural re-education.
What Can I Do to Improve My
•Standing balance exercises
• Thorough evaluation to determine
where deficits are coming from
• Choosing appropriate treatment method
• Compliance with home exercise