Vestibular rehabilitation is a term to describe certain treatment techniques and exercises used to treat a number of conditions that causes a disturbance in balance and proprioception, dizziness and nausea. Some of these conditions include Vertigo, Benign Positional Paroxysmal Vertigo (BPPV), Vestibular Neuritis and even concussion.
Vertigo is mostly a symptom of another condition or underlying cause and is described as a spinning sensation. It is different to just feeling off balance or lightheaded. Vertigo describes an illusion of movement, where it feels that you yourself or your environment is moving.
BPPV is the most common cause of vertigo and is believed to occur due to a displacement of small crystals in the inner ear. These crystals end up in the fluid canals in the inner ear, which are very sensitive to gravity. Therefore, the main characteristic of BPPV is that a change in the position of the head causes an episode.
BPPV can be triggered by:
- Tilting the head
- Rolling over in bed
- Looking up or under
- Sudden head movements
It could also be made worse by factors such as stress and a lack of sleep.
BPPV could be a result of degenerative changes that comes with age, trauma (head injury), vestibular viruses or a side effect of surgery.
Symptoms of a BPPV episode includes:
⦁ Vertigo – a spinning sensation
⦁ Short duration – lasts only a few seconds to a minute
⦁ Positional – it is induced by a change in the position of the head
⦁ Nausea
⦁ Visual disturbances – difficulty reading or seeing
⦁ Feeling faint or fainting
⦁ Vomiting
⦁ Loss of balance
⦁ Nystagmus – eye rotates towards the affected ear in a beating or twitching way
Risk factors for BBPV:
- Female
- Menopausal age
- Hypertension
- Allergies
- Migraine
- Surgical procedures such as cochlear implants
Sport – related concussion may be another cause of vertigo symptoms, like dizziness and balance disturbances. This is often due to a dysfunction of the vestibular system. The cervical spine trauma that usually occurs with a concussion can lead to headaches.
How to stop the spinning?
BPPV symptoms do not always require intervention, it may resolve itself, however if it does not resolve the following management might be needed.
Medical management:
- Surgery: nerve neurectomy or posterior canal occlusion
- Medication: cannot directly treat BPPV, but could treat the symptoms such as dizziness and nausea
PHYSIOTHERAPY MANAGEMENT:
Repositioning procedure
These procedures make use of gravity to move the calcium crystals from the inner ear.
Epley Maneuver
Patient starts in long sitting, head rotated 45 degrees to affected side
Patient rapidly reclined to supine position with neck slightly extended. Hold position for 30 seconds, or until nystagmus and dizziness subside
Rotate head 90 degrees to opposite side. Hold position for 20 seconds, or until nystagmus and dizziness subside
Patient rotated 90 degrees from supine to side lying. Hold position for 20 seconds, or until nystagmus and dizziness subside
Bring patient up into short-sitting
Manual Therapy
Vertigo as a result of sport-related concussion might include neck pain and headaches. In this case manual therapy (joint mobilization techniques) of the cervical and thoracic spine would be beneficial. Soft tissue release / massage of the neck, upper back and shoulder muscles would decrease stiffness and spasms that occurs as a secondary problem.
Exercises
- Activation and strengthening of the deep neck flexor muscles, the stabilizing muscles of the cervical spine.
- Sensorimotor retraining
Vestibular Rehabilitation
The goals of vestibular rehabilitation are:
1) enhancing gaze stability,
2) enhancing postural stability,
3) improving vertigo and
4) improving activities of daily living.
Enhancing gaze stability
- The patient maintains visual fixation on a target while moving their head in a vertical or horizontal plane. The target can be either at arm’s length or across the room. Various amplitudes of head movements are used to increase the effectiveness. Further progression includes focusing on a target that moves in the opposite direction as your head movement.
This exercise should be done 4 -5 times daily for a total of 20 – 40 minutes/day.
- The patient looks directly at a target, head aligned with the target; then look at the second target (only with eyes, not turning head); then turn your head to the second target.
- Look directly at a target, head aligned with the target; close your eyes; slowly turn your head away from the target while imagining that you are still looking directly at the target; open your eyes and see if you were able to keep your gaze on the target.
Enhancing postural stability
- This involves a number of different types of exercises and techniques. The patient’s sitting and standing balance and proprioception will be tested. These tests might include taking away one or more senses, for examples closing your eyes or putting in earplugs. Unstable or moving surfaces might also be used.
- Sitting postural stability exercises:
1. Eye and head movements as described above, while sitting.
2. Shrug and moving your shoulders in circles
3. Bend forward and pick up objects from the floor.
4. Bend side to side to pick up objects from the floor.
- Standing exercises:
1. Eye, head and shoulder movements as above
2. Change from sitting to standing, first with eyes open and then shut.
3. Throwing a ball from one hand to the other at eye level, and then under knee level.
4. Change position from sitting to standing with turning around inbetween.
- Walking exercises:
1. Walk up and down a slope
2. Walk up and down stairs
3. Walk while throwing and catching a ball
4. An activity including stooping, stretching and aiming e.g bowling
Improving vertigo
- Repositioning exercises as explained above in Physiotherapy management.
Improving activities of daily living
- If the above-mentioned steps of vestibular rehabilitation is done properly then the patient should be able to return to normal work and daily activities. The exercises should be integrated into the patient’s daily routine.
... So, lets get your land legs back and stop your world from spinning…
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