Introduction |
DiagnosisA detailed history of your problem is the most crucial information needed by your physiotherapist in order to diagnose the cause of your vestibular disorder and then to implement the appropriate VRT. Advanced TestingElectronystagmographyElectronystagmography (ENG) is a commonly used test to check for signs of nystagmus in more detail. Caloric testingDuring this test, which is a subtest of electronystagmography, cool and warm water or air is administered to each ear, one at a time. The change in temperature stimulates the balance organ in the ear and in normal circumstances your eyes reflexively move in a specific direction depending on whether cool or warm water is administered. Absence of this movement indicates a vestibular problem. Rotation TestsNormally each time your head moves one way your eyes move in the opposite direction. During rotation tests electrodes or goggles are used to record how the eyes move while the head is moving at differing speeds. You may be asked to move your head while looking at a fixed target, or a computerized chair may be used to rotate your head while it is restrained. Vestibular evoked myogenic potential (VEMP)This test is used to confirm whether or not the saccule and part of the vestibular nerve are functioning properly. PosturographySometimes called computerized dynamic posturography, this test provides information about motor control and balance function during varying unstable conditions. Rather than providing specific information about the vestibular portion of the ear or brain, this test focuses on the feedback needed by the receptors in one’s joints, muscles, and skin (proprioception) in order to maintain one’s balance. ScansIn some cases a magnetic resonance imaging (MRI) scan or a computerized tomography (CT) scan of the brain may be done. An MRI scan uses a strong magnetic field and radio waves in order to produce a detailed image. A CT scan uses a series of detailed X-rays to create an image. Hearing TestsStandard hearing tests are often carried out when delineating the cause of vertigo due to the close relation between the hearing and balance organs and nerves of the ear. Vestibular Rehabilitation Therapy ExercisesAs indicated above, a wide variety of disorders that cause dizziness or imbalance can be treated with VRT. Virtually any disorder that is due to a vestibular dysfunction, and is not being well compensated for, can be treated with VRT. Effectiveness of VRT depends on a proper diagnosis of the cause of the imbalance, the skill/training of the therapist designing and administering the treatment, and the adherence to the exercise program prescribed. VRT ExercisesIf your physiotherapist feels that VRT is appropriate for you after your assessment is complete, they will prescribe a number of individualized exercises for you to regularly perform. These exercises will address your specific vestibular problem and the related symptoms. In addition, the exercises prescribed for you will focus on any everyday issues you are facing as a result of your symptoms. Some exercises will be performed with your physiotherapist at In Balance Physiotherapy and others will be taught to you such that you can complete them independently as part of a home exercise program. Medications to treat your symptoms can be an adjunct to VRT and should be discussed with your physician. Adaptation Exercises These exercises work to force the vestibulo-ocular reflex (VOR) to adapt to movement of the head. In a way it is encouraging the eye-ear-brain connection to ‘reset’ itself. Substitution Exercises The purpose of these exercises is to use visual cues and those coming from the joints and muscles, to make up for the loss in vestibular sensory cues. These exercises work to improve gaze stability and postural stability. Habituation Exercises These exercises work to decrease the magnitude of the vestibular symptoms one feels by repetitively exposing the system to stimuli that bring on the symptoms. These exercises attempt to fatigue the vestibular response to the stimuli such that symptoms decrease over time. An example is putting your head down towards your knees in sitting and then back up. This exercise is repeated several times a day. The severity and duration of the dizziness felt after the exercise should be recorded. Compensation Exercises These types of VRT exercises encourage other systems and mechanisms associated with balance in the body to work harder in order to counteract the diseased vestibular system. They can include substitution type exercises but also include more generalized central nervous system based strategies. Often patients have already developed their own compensatory strategies by the time they have visited one of our physiotherapists. It is the job of your physiotherapist to help identify which strategies are in use and to assist you to use these strategies more effectively to manage your disease and symptoms. Canalith-Repositioning Maneuver or Exercises These exercises are used when otoconia (also called canalith) have settled in the semicircular canals and are causing vertigo and other symptoms. The treatment of BPPV is often successful with this type of VRT. Common maneuvers your physiotherapist may use are called the Epley Maneuver or the Semont Maneuver (also called the Liberatory maneuver.) Both maneuvers involve your physiotherapist holding your head into a certain position and then lying you down onto your back or side. If successful this motion dislodges the canalith and moves it into the inner ear area where it no longer causes symptoms. When these maneuvers work to treat BPPV, they often work quickly, even in just one treatment session. Machine-based Exercises There are several machines that have been developed to challenge the vestibular system and therefore may be used in VRT if available. Examples include virtual-reality type simulators and moveable standing platforms. The benefit of these types of exercises is that the parameters of the exercise can be objectively set and measured, which allows objective improvement to also be measured. In addition, with some machines, once the program is set up, less direct therapist supervision may be required which allows more patient independence. With most types of VRT machines feedback is also provided, which enhances the learning ability. Home videos have also been developed for similar purposes. Gait Retraining These types of exercises work specifically on how you walk. Many people with vestibular issues develop an inefficient gait pattern. Your physiotherapist will assess your walking pattern and will prescribe specific exercises to address any issues you may have developed to compensate for your vestibular symptoms. General Exercise Many patients with a significant or chronic vestibular disorder avoid activity due to it bringing on their symptoms. These patients, particularly if of an elderly age, quickly become deconditioned. For these patients a general exercise regime aimed at improving cardiovascular health will be prescribed by your physiotherapist. The initial activity recommended is generally regular walking on even terrain, which should be done in a quiet and calm environment. As general cardiovascular health improves and normal walking is tolerated by the vestibular system then walking on uneven terrain and/or on a busy street where increased head movement is required can be initiated. Other general recreational activities such as golf, bowling, swimming or any other activity that you may enjoy can be discussed with your physiotherapist and added at their discretion. Manual Neck TreatmentSome patients who experience dizziness or balance issues have a concurrent orthopaedic problem with their neck, which is causing or adding to their symptoms. In some cases this may be the original problem and in other cases a problem in the neck may have developed due to an existing chronic vestibular problem which in turn causes decreased voluntary head and neck movement. In these cases your physiotherapist at In Balance Physiotherapy may also do some hands-on treatment for your neck in combination with the other VRT exercises described above. EducationSecondary injuries due to vestibular problems can easily occur due to frequent falls or near-miss falls. As part of your VRT your physiotherapist will ensure you are well educated regarding simple strategies that can minimize your risk for secondary injuries. For example, the use of a walking aid when you are tired or in a particularly busy environment, such as a grocery store, may be advised. Motion lights or night lights for during the evening hours or nighttime near the entry doors may be encouraged. |