by Melissa Seifried MScPT and Joon Nah BScPT
Vestibular physiotherapists (Cornerstone Dizziness Clinic)
updated Jan 11, 2022
What is Vestibular Rehabilitation?
Vestibular rehabilitation therapy (VRT) is a specialized form of physiotherapy prescribed to treat and improve the symptoms caused by vestibular disorders. It often involves manual head manoeuvres and/or a progressive program of exercises designed to reduce vertigo and dizziness, visual issues, and/or imbalance and falls.
After an injury to the vestibular system occurs, the central nervous system can compensate for reduced function of the inner ears. Essentially, the brain copes with the imbalanced signals coming from the vestibular system by learning to rely more heavily on alternative signals coming from other systems in the body to maintain vestibular balance. This can be achieved through various exercise strategies outlined below. When this central (or brain) compensation occurs, the patient’s symptoms can be alleviated and allows them to return to normal function.
What is the Vestibular System?
Your vestibular system helps you detect head position and motion and it allows you to properly react when it senses changes to it. It is made up of 1) your two inner ear organs 2) the vestibular centres of your midbrain and cerebellum and 3) your peripheral vestibular nerves.
The vestibular organs in your inner ears act like sensors that measure head rotation, forward/back and up/down motions and head tilt. It is often called a labyrinth due to the many loops of the semi-circular canals that is contained within. The vestibular nerve connects your inner ear organ to the midbrain and cerebellum towards the posterior of your brain. These vestibular nerves transmits the motion information from the inner ears to your brain for processing.
Your brain processes information from your inner ear organs but gets backup information from other senses such as your vision, the joints, muscles and tendons throughout your body, from hearing, touch and even functions such as memory and emotion. It then send outs nerve impulses to the muscles in your eyes, trunk and limbs so that you react appropriately to each situation.
What Types of Problems Benefit From VRT?
Patients typically referred for Vestibular Rehabilitation have been diagnosed with a vestibular condition including:
- Benign Paroxysmal Positional Vertigo (BPPV)
- Vestibular Neuritis/Labyrinthitis
- Unilateral Vestibular Hypofunction (UVH)
- Vestibular Migraine
- Persistent Postural Perceptual Dizziness (PPPD)
- Mal de Debarquement (MdDS)
- Cervicogenic Dizziness
- Post Concussion Syndrome (PCS)
- Meniere’s Disease
- Neurological conditions (i.e. stroke, traumatic brain injury)
- Vestibular deconditioning from aging or inactivity
- and many other vestibular conditions….
If you have not yet been assessed or diagnosed with a vestibular condition, common symptoms that can be helped with vestibular rehabilitation include:
- Vertigo (sense of spinning)
- General dizziness or lightheadedness
- Nausea, vomiting, fatigue
- Neck tightness, stiffness and/or pain
- Imbalance and difficulty walking
- Frequent falls
- Vision issues (double vision, shaky vision with head movement, difficulty focusing, poor tolerance to screens)
- Brain fog, difficulty concentrating, mild memory issues
Is Vestibular Rehabilitation Therapy Right for Me?
If you suffer from one or more of the symptoms noted above, then Vestibular Physiotherapy will likely be helpful. However, it is important to note that many dizziness complaints can also be caused by a large list of other potential factors that do not involve your vestibular system (Here are the 10 most common). You must be appropriately assessed in order to determine whether or not you have a vestibular condition and if you will benefit from vestibular rehabilitation.
Vestibular rehabilitation centres such as the Cornerstone Dizziness Clinics will carefully consider the onset and progression of your condition, your symptoms and episodes, your other related medical history. They will also perform a medical evaluation that involves:
- Central neurological testing (various reflex tests)
- Cranial nerve tests of specific brain-based functions
- Cervical tests of your neck’s joint, blood flow and muscle function
- Visual oculomotor function tests
- Balance testing
- Gait assessment (walking / mobility tests)
- Positional testing on a table
- Frenzel or Infrared Goggle tests to view and record nystagmus (reflexive eye movements)
Based on the findings of your assessment, your physiotherapist will determine if you are an appropriate candidate for vestibular rehabilitation therapy. The goal of your treatment plan will be to improve any deficits that were identified in the assessment. This, in turn, will help to improve your daily symptoms and your ability to function in activities of daily living.
How Do You Do Vestibular Rehabilitation Therapy?
Vestibular rehabilitation exercises are not difficult to learn but require a high degree of consistency by the patient to achieve success. We often recommend the exercises be performed a minimum of 2-3 times in a day, which can be tedious or difficult to incorporate into a busy schedule. We suggest that our patients set up a regular schedule so that the exercises can be more easily be incorporated into your daily routine.
In most cases, patients will notice that the vestibular rehabilitation exercises will somewhat increase their symptoms. Generally, this means that you’re doing the exercises properly and stimulating your vestibular system appropriately. But with time and consistent work, your symptoms should decrease until they are are more manageable and in many cases, completely resolved. We often use a weight lifting analogy: when you first start lifting a certain amount of weight, it is difficult and your muscles are sore after your workout. But, over time, the weights become easier to lift and your muscles hurt less over all. It is then that you are ready to progress to lifting heavier weights, or in the case of vestibular rehabilitation, performing more complex vestibular exercises.
NOTE: If you have a diagnosis of Benign Paroxysmal Positional Vertigo (BPPV) then treatment primarily involves maneuvers to reposition the dislocated inner ear crystals. In some cases vestibular rehabilitation home exercises are required as a part of the manual treatments required to improve BPPV. Learn more about BPPV here.
What are the types of exercises I will learn in a vestibular rehabilitation program?
Every patient’s vestibular rehabilitation exercise program is different from each other. This is not only because there are different types of vestibular impairments, but each type affects everyone differently. No two cases are identical. Our Cornerstone Dizziness Clinics are often see poorly functioning patients that were given generic exercise handouts or put through a general vestibular program. Once the patient’s specific impairments were considered AND proper changes to the exercise program introduced at the right time in their recovery, the patients reported improvements again.
Vestibular rehabilitation exercises allow for central brain compensation to occur, which realigns the function of your vestibular system’s impairments. This compensation can typically be divided into three categories
This is a process where nerve impulses in the brain are able to shift or “adapt” to the incorrect signals from the damaged vestibular system. This gradual shift allows your brain to recalibrate itself.
This process allows you to gradually desensitize yourself to vestibular movement and stimulation if you are repeatedly exposed to it.
This recovery principle uses other body functions or strategies to replace the missing vestibular function
Here are some examples of common vestibular exercises used in vestibular rehabilitation.
Habituation exercises are used to treat symptoms of dizziness that are produced because of head motion or visual stimuli. These patients typically report increased dizziness when they turn their heads quickly or with position changes like bending forwards to tie their shoes or looking upwards. Habituation exercises are also appropriate for patients who have difficulty in highly visually stimulating environments like grocery stores and busy gyms, as well as when looking at screens. The primary purpose of a habituation exercise is to reduce symptoms through repeated exposure to specific movements or visual stimuli that provoke dizziness. These exercises are designed to provoke a mild level of symptoms to allow the central nervous system to gradually “habituate” (get used to) the stimuli. The increase in symptoms should only be temporary and should return back to baseline after 15-20 minutes. Over time and with excellent compliance to the program, the intensity of dizziness with these exercises should decrease as the brain learns to ignore the abnormal signals it is receiving from the inner ear system.
Gaze Stabilization Exercises
Gaze stabilization exercises are used to improve visual acuity and steadiness during head movements. These exercises are recommended for patients who report that their visual world appears to wiggle, shake, shift, or move when reading, walking, changing position, or when trying to identify objects in the environment. A very common exercise to promote gaze stability involves working on your VOR (vestibular-ocular reflex) by fixating on an object while you repeatedly moves your head back-and-forth or up-and-down for several minutes.
Balance Training Exercises
Balance training exercises are a staple of vestibular rehabilitation and used to improve steadiness so patients can more successfully participate in activities of daily living, work and leisure or physical activities. After assessing several measures of your balance, your physiotherapist will provide you with exercises that are moderately challenging but safe enough so you do not fall while performing them. Ultimately, these balance exercises should help improve your ability to walk outside, on uneven ground, or navigate your environment in the dark. A comprehensive balance training program should help improve your ability to sit, stand, walk, turn, bend over, and reach while maintaining your balance. It is the goal of vestibular physiotherapy to help you get back to as many of your desired activities as possible, including running or sports.
Additional vestibular rehabilitation therapy exercise could include:
- visual targeting and tracking exercises
- convergence exercise for near and far visual shifting
- gait or walking and mobility exercises
- neck stretching and core strengthening
- dual or multiple stimuli coordination
- postural training and education on ergonomics
As stressed earlier, no two vestibular rehabilitation exercise programs are exactly alike. Your exercise program should be developed by a vestibular physiotherapist who has identified your specific impairments and the challenges and limitations based on your lifestyle, occupation and roles. . If you have tried some exercises you found online and didn’t notice any change, the exercises may not have been appropriate for you specifically!
I think I may have BPPV? Should I try vestibular rehabilitation?
Benign Paroxysmal Positional Vertigo (BPPV) is a common cause of vertigo. It is important that you are appropriately assessed in order to be diagnosed with this condition. Your vestibular physiotherapist is trained to assess your inner ear organs with positional testing which puts your head in different angles to try reproduce your vertigo while carefully noting the related nystagmus or patterns of eye reflexes. Repositioning maneuvers are then used to treat the specific type of BPPV that has been identified. For more information on this, click on the link above.
After BPPV has been successfully treated with repositioning maneuvers, some individuals will continue to report more generalized dizziness or imbalance that persists over time. In these cases, the prescription of habituation exercise and/or balance training may be appropriate.
How long is a typical vestibular rehabilitation program?
The length of time for recovery is highly variable and can be as few as a couple of visits or can be chronic condition that is managed over years. Our Cornerstone Dizziness Clinics typically see patients once per week or less, for 1-3 months. But this varies based on the patient’s diagnosis, severity of symptoms, and their response to therapy. The effectiveness of the exercise program depends not only on the exercises chosen by the physiotherapist but also on the patient’s adherence to the program. The most common reason for a delay in recovery is an inconsistent performance of the prescribed exercises.
What type of recovery or outcome can I expect from vestibular rehabilitation?
Expected vestibular rehabilitation outcomes include:
- Decreased dizziness symptoms
- Decreased nausea or vomiting
- Improve focus or concentration and memory
- Improved balance in standing or sitting
- Decreased risk of falling
- Improved ability to stabilize gaze or vision and ability to track or focus on objects near and far
- Improved neck mobility, stiffness and/or pain
- Less fatigue and improved sleep
- Decreased anxiety and depression and better ability to cope with stress
- Increased confidence to return to desired activities and hobbies
Does Vestibular Rehabilitation Therapy Work?
YES! Overwhelming evidence has proven that VRT is effective in improving symptoms in various vestibular conditions including unilateral vestibular hypofunction, chronic dizziness, vestibular migraine and tension type headaches, PPPD, concussion and many others.
Vestibular Rehabilitation Near Me.
Cornerstone Physiotherapy has been treating patients with dizziness and concussion since 2008 and offers vestibular rehabilitation at all of our locations including in Toronto, North York, Burlington and Markham. For those that find it difficult to reach a clinic or live in further regions of Ontario, we offer vestibular assessments virtually where a customized vestibular rehabilitation exercise program can be developed and taught to you over video telehealth by a registered vestibular physiotherapist.
If you are unsure if our services are appropriate for you, we offer a free 10 minute phone consult with a vestibular physiotherapist who can provide you with honest advice about your treatment options.
Questions? We're happy to help!
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