Vestibular Disorders

Semicircular Canals

WHAT IS THE VESTIBULAR SYSTEM?
The vestibular system is composed of the brain and structures in the inner that allow you to orient your head in space and ultimately control balance. The inner ear houses the cochlear and vestibular nerves, and consists of 3 semi-circular canals oriented in various angles, filled with fluid. The movement of the fluid in the canals allows the brain to detect acceleration of movement. At the base of the canals are the utricle and saccule, organs that help detect the orientation of the head in space. The utricle and saccule organs house small receptors called macula that contain crystal-like otoconia. When the head and body are bent forward to look down, for example, the fluids in the canals move and stimulate the macula and otoconia, which then relay information to the brain that the head is moving forward and downward and at what rate or speed. The vestibular system is also directly linked to the visual system via the vestibular ocular reflex, allowing the brain to use vision as another source for maintaining balance and equilibrium. Lastly, the body will incorporate sensory information from the extremities (somatosensory system) to aid in balance and equilibrium. When these 3 systems (vestibular, visual, and somatosensory) have deficits or are absent, an individual's balance is negatively affected.

VESTIBULAR DISORDERS
There are many different vestibular disorders with varying symptoms, including dizziness or vertigo, visual disturbances, and/or a decrease or complete loss of hearing. A brief description of the common disorders we treat are listed below. For more information on these and other vestibular disorders, please visit http://vestibular.org/about_balance.

Cervicogenic Dizziness

This condition is somewhat difficult to diagnose because there are no specific tests to confirm it. However, individuals with neck pain as a result of arthritic changes or trauma have been known to complain of dizziness. Symptoms usually occur with prolonged neck pain, but may also occur with head and neck motions. Manual therapy to the neck and surrounding muscles to restore motion and decrease pain usually help resolve issues with dizziness.

Benign Paroxysmal Positional Vertigo (BPPV)

Vestibular Disorders

BPPV is the most common cause of vertigo and imbalance. The name implies that it is not a life-threatening condition, in which symptoms occur suddenly and last for relatively short periods of time based on head positions or movements. It occurs when the otoconia break loose and flow within the semi-circular canals, leading to symptoms of vertigo and dizziness by giving the brain a false sense of movement. There are 2 types of BPPV, based mainly on symptom behavior. With canalithiasis, there is a latency period of onset of dizziness after the head has been moved, and symptoms will last no greater than 60 seconds. With cupulolithiasis, symptoms are brought on immediately with head movement and will generally last slightly longer than 1 minute. There are specific tests to confirm these conditions as well as very specific maneuvers to reposition the otoconia and restore balance.

Vestibular Neuritis/Labyrinthitis
These two conditions are disorders which arise from an infection that leads to inflammation of the inner ear or the cochlear and/or vestibular nerves that relay information to the brain. Vertigo, dizziness, visual disturbances, and/or hearing loss may be present. Neuritis is inflammation of the vestibular nerve that affects balance associated with vertigo or dizziness. Therefore there is no loss of hearing. Labyrinthitis is inflammation of that affects the cochlear and vestibular nerves, resulting in hearing deficits as well as difficulties with balance. It is essential that these conditions be properly diagnosed by a physician and properly treated before the first physical therapy visit because physical therapy cannot treat the infection but rather the deficits in balance.

Ménière's Disease
This is a chronic and incurable inner ear disorder where the inner ear produces excess amounts of fluid (endolymph) that leads to recurring symptoms. This condition can develop at any age, but tends to happen in adults between 40 and 60 years of age. Although physical therapy cannot "cure" the condition, it can help improve some deficits of imbalance as well as coping mechanisms.

Unilateral and Bilateral Vestibular Hypofunction
Unilateral refers to one side, bilateral refers to both sides, and hypofunction refers to functioning or working below optimal level. Generally, when there is a deficit in the vestibular system, it is unilateral (UVH) and, therefore, the unaffected side is working optimally. In some cases the vestibular system can be affected bilaterally (BVH), so the symptoms are more drastic and recovery is limited. In BVH, improvements in balance, hearing, and vision can be made, but some deficits may be permanent. It is important, in cases of BVH, to diagnose of root cause because it is more serious than UVH.

Post-Surgery
In some vestibular disorders, such as with acoustic neuroma and periplymph fistula, surgery may be necessary to correct the cause of vestibular dysfunction. Physical therapy can then help in the recovery process in order to improve visual disturbances and imbalance.

WHO WOULD BENEFIT FROM VESTIBULAR THERAPY
It is important that all individuals who are referred to physical therapy for vestibular rehabilitation be diagnosed with a specific disorder because not all vertigo and dizziness are due to vestibular dysfunctions. For example, some dizziness can be related to the interaction of the various medications that someone may be taking for multiple medical conditions. Furthermore, proper diagnosis will ensure a better treatment plan and future outcome.

VESTIBULAR DYSFUNCTIONS WE TREAT

  • Cervicogenic Dizziness
  • Benign Paraxysmal Positional Vertigo (BPPV)
  • Canalithiasis and Cupulolithiasis
  • Vestibular Neuritis
  • Labyrinthitis
  • Ménière's Disease
  • Post-surgery
  • Unilateral and Bilateral Vestibular Hypofunction

VESTIBULAR THERAPY AT TOUCH OF LIFE PT

  • Canalith Repositioning
  • Habituation Techniques
  • Adaptation Exercises
  • Substitution Strategies
  • Gaze Stabilization Exercises
  • Gait and Balance Training
  • Transfer Training
  • Core/Generalized Strengthening
  • Fall Prevention
  • Self-Management Techniques
  • Patient and Family Education

REREFENCES:

  1. http://vestibular.org/about_balance (Accessed on 11/08/2016)
  2. Moore, S. Differential Diagnosis and Treatment of Common Vestibular Disorders. Published for the Neurology Section of the American Physical Therapy Association (Accessed 11/08/2016)
  3. Shumway-Cook, A. Vestibular Rehabilitation - An Effective, Evidence-Based Treatment. Publication for Vestibular Disorders Association; Portland, OR.
  4. Herdman SJ, editor. Vestibular Rehabilitation. 3rd ed. Philadelphia: F.A. Davis Co.; 2007