Dizziness & vestibular physiotherapy
Dizziness is a surprising commonly problem affecting people today, resulting in many people presenting to the Emergency Department or to their GP every year. Dizziness can have a profound effect on an individual’s quality of life – affecting the most basic of activities of daily living such as getting up from a chair, crossing the road, completing work demands as well as negatively impacting on social and sporting activities.
Fortunately, Physiotherapist’s can help. Physiotherapy has an important role in managing the symptoms resulting from a vestibular condition – whether it be in the hospital Emergency Department or in the private practice setting in the community.
What are the symptoms associated with a vestibular condition?
There are many variable symptoms associated with dizziness and various types of vestibular dysfunction, depending on the particular condition. Symptoms may include the following:
Vertigo and dizziness
A sensation of lightheadedness, a swaying sensation – the sensation of being on a boat or of the room spinning around you.
Difficulties with depth perception and difficulty walking in the dark.
Nausea and vomiting
This can also be a seasick like feeling or motion sickness.
Hearing changes, difficulty coping in loud social situations and tinnitus or ringing in the ear.
Difficulty focusing or tracking objects, visual changes as well as inability to cope with busy environments – crossing the road, negotiating crowds for example.
Poor balance and difficulty with spatial orientation. This may result in stumbling, difficulty walking straight as well as issues with negotiating corners, steps, uneven terrain, change of footwear. Falls or a fear of falling may result from poor balance – especially in older individuals.
Loss of confidence, anxiety, fear of falling, difficulty coping with social situations and busy or noisy environments, depression.
Sufferers of vestibular dysfunction may find that their posture changes as a result of needing to keep their eyes on the ground or due to a need to hold onto their head or onto objects in the environment.
Conditions which may cause dizziness
There are many conditions which may cause dizziness, including but not limited to the following:
- BPPV – Benign Positional Paroxysmal Vertigo
- Meniere’s disease
- Acoustic neuroma
- Age related dizziness and imbalance
- Vestibular neuritis
- Migraine associated vertigo
- Cervicogenic dizziness (related to neck pain and stiffness)
- Low blood pressure
- Stroke or TIA
As there is a significant risk that dizziness may be resulting from a medical condition, for example low blood pressure, a cerebrovascular event such as a stroke, TIA or due to various neurological conditions – it is strongly recommended that you see your G.P. for a medical assessment and advice before consulting your physiotherapist for further assessment and management advice regarding potential vestibular disorders.
So how can physio help sufferers with this disorder?
To answer this question, we will first explore what the vestibular system is, how it functions normally as well as exploring what balance is, and how the body maintains equilibrium in an ever changing environment.
What is Balance?
Balance is the body’s ability maintain posture whilst adapting to changes in the environment – balance allows us to maintain our center of mass over our base of support. A balance system that is working well allows us to move our eyes and our head to see around us, bend over to pick up items, reach outside our base of support, negotiate steps, obstacles and uneven or changing terrain without losing our balance and falling over.
Maintenance of balance is quite complex from a neurophysiological perspective but can be broken down into three main systems or functions.
- Sensory information
- Sensory integration
- Motor output or function
The body receives sensory information and feedback from its environment.
Touch and pressure receptors in our skin along with pressure and joint position receptors in our joints and muscles tell us what type of surface we are standing on – for example how firm the ground is, does the ground soften and give way under our feet like sand, is it smooth and flat like our kitchen floor is, or is the ground rough and rocky.
Our eyes tell us where we are positioned in space and in relation to the ground.
Finally, our vestibular system allows us to identify what position we are in relative to gravity and has an important role to play regarding our ability to sense and analyze motion, equilibrium and our orientation in space.
The next step is sensory integration. This is where our peripheral and central nervous systems come into play. Peripheral sensory nerves send messages to the brain – relaying information about what our bodies sensory systems are sensing. The brain then processes this information and decides how to respond. Many of these responses are automatic and reflexive in nature – most of the time we are not even aware that they are occurring.
The cerebellum (the coordination center of the brain) and the cerebral cortex (the thinking and memory center) have a critical role to play in sorting through new information coming from the sensory organs of the body and incorporating these new messages with what we already know about the environment (learned information). The cerebellum stores information about movements that are automatic – for example riding a bike becomes an automatic movement through repetition and practice. The cerebral cortex contributes by sharing memories about situations we have encountered in the past.
The final stage of maintaining our balance is motor output. This is the phase where our body physically reacts to the sensory stimuli it receives. For example reflexes allow our eyes to adapt to head position changes and muscles will be instructed to move the body in a manner that allows us to respond to a change in terrain or environment – perhaps preventing a fall from occurring.
The Vestibular System
The Vestibular Apparatus is a small, complex structure located in the inner ear. It is found deep within the temporal bone of the skull where it is well protected from the outside environment and from trauma. With the apparatus there are five sensory organs, which together work to detect head movements and changes in posture and position relative to gravity. The vestibular apparatus detects these movements and transduces this information into electrical signals which the peripheral nervous system then picks up and sends this information to the central nervous system, including the brain.
The otolith is an organ containing two structures: the saccule which detects vertical movements and the utricle which detects horizontal movements. These structures are sensitive to gravity, linear acceleration and head tilt. Tiny calcium carbonate crystals sit in a jelly like material which in turn sits on top of tiny hairs lining the otolith organ itself – movement stimulates the crystals, which in turn stimulates the tiny hairs lining the otolith. It is the movement of these tiny hairs which stimulates the nerves, generating electrical messages which are sent to the brain, ultimately telling us what position we are in space.
The other three organs are three semicircular canals which are orientated at 90 degrees to each other in an anterior, posterior and horizontal position. These canals are sensitive to head motion in an angular or rotational direction. Again, any movement which causes displacement of specialized hair cells located within each sensory organ will stimulate neurons to send information to a specialized region of the brain, the cerebellum, which has an important role in balance and coordination.
All this information is linked in with a set of eye and postural reflexes. The central nervous system integrates information received from both the vestibular system, our sensory organs (for example the skin, joint position receptors in our limb joints as well as visual information from our eyes) and from our brain. Automatic reflexes allows to remain upright against gravity, allows for optimal eye position as well as generating compensatory body movements to maintain stability whilst the head is moving.
Rehabilitation strategies for vestibular conditions
Benign Paroxysmal positional Vertigo (BPPV) is a condition affecting the vestibular apparatus of the middle ear. An acute BPPV episode is characterized by dizziness (a spinning or swaying room), nausea and vomiting. A vestibular physiotherapy assessment can assess for this condition by taking a detailed history of the presenting complaint along with utilizing specific vestibular assessment tests. Specific BPPV treatment techniques along with an individualized rehabilitation exercise program will help to get you back on track.
After an acute episode of vestibular dysfunction, the body needs to relearn how to cope with normal everyday head, neck and body postures and movements. An individualized rehabilitation program incorporating habituation exercises will help with this.
Falls education and Balance re-training
Education regarding strategies on how to prevent falls is important for those people who have balance deficits. Particularly relevant for the elderly – a balance assessment combined with an individualized and specific balance re-training program helps to improve balance, confidence and ability to mobilize safely.
A physiotherapist can assist you with adapting your lifestyle whilst coping with a vestibular disorder, for both acute conditions and chronic conditions.
A physiotherapy assessment and hands on physiotherapy can assist with management pain and dysfunction resulting from compensatory strategies that are developed as a result of trying to cope with the symptoms of a vestibular disorder. Such techniques include:
- Posture re-training
- Soft tissue therapy
- Manual therapy – joint mobilization
- Dry needling
- Stretching and flexibility exercises
- Strengthening – including Pilates exercises
If you wish to see a physiotherapist regarding a potential vestibular disorder, please let our receptionist know when booking an appointment, so that you are booked in to see a physiotherapist who has additional postgraduate training and experience in vestibular rehabilitation.