Balance and Vestibular Disorders

This blog was transcribed from our 5th episode of our Spine & Rehab Specialists podcast series featuring Harry Koster, PT, Cert. MDT and Marlene Gomez, PT, DPT. Scan this QR code or click the button on the right side of this page if you are interested in listening to this, or any of our other episodes!
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The vestibular system, in a simple definition, involves a set of small structures inside the inner ear that help detect information about the position and movement of your head in relation to your body and in relation to your surroundings. And by doing this, it provides us with our sense of motion and position, which really comes into play with balance. And it’s not only this sense of movement that helps contribute to maintaining our balance, but the vestibular system also helps use this information to create reflexes to help correct and maintain our postures, our visual stability, which we refer to as gaze stability, and of course our balance.
 
What happens when the vestibular system becomes affected? What kinds of symptoms do people experience?
 
The typical symptoms that people have are dizziness, vertigo, balance difficulties, visual disturbance, and sometimes even hearing impairment. But most of these symptoms occur because the vestibular system is no longer functioning properly to process the information about head and body position effectively, so the information you are receiving will lead you to feel that you are maybe moving when you are actually still or that you moved a lot faster than you actually did. It is important to note that the terms vertigo and dizziness are actually not the exactly the same; the term vertigo really describes a sensation of spinning.
 
These symptoms are not always due to something in the vestibular system, it is important to note that other factors have to be considered when dealing with symptoms of dizziness or vertigo, such as medications, as many will list dizziness as a side effect.  Blood pressure is also another important one to consider, especially if someone mentions that they become dizzy or lightheaded when they stand up. History of stroke or brain injuries, or other neurological conditions or problems such as tumors in certain areas of the brain, can also have symptoms of dizziness. And even problems in the cervical spine in which case people tend to respond well to treatments for the neck.
 
There are various conditions that can affect the vestibular system, two specifically that I would like to focus on in greater depth as they tend to be more common.
 
BPPV – Benign Paroxysmal Positional Vertigo
 
Vertigo is one of the hallmark signs of the first condition I wanted to talk about which is BPPV. This is one of the more simple conditions, and it is something that we have previously discussed in one of our Sunday stroll videos.  In this condition there are these small structures, which are typically described as small rocks or crystals, that become dislodged from the area they are typically contained in, and become stuck within the canals of the vestibular system. While in these canals, these crystals will move every time you move your head or change your body position, which will stimulate the sensation of spinning.
 
This condition has very specific signs and symptoms, one being vertigo that lasts usually less than one minute. It typically takes a few seconds for symptoms to be reproduced with specific movements, and another is a specific eye movement, which is called Nystagmus, that occurs briefly during these episodes of vertigo
 
BBPV is pretty common and something we see in the clinic quite often due to the fact that the crystals previously mentioned may become dislodged with some sort of head trauma, or even with a sudden brisk movement of the head. Which is something that can really catch someone off guard, because of how sudden it can develop.
 
The second condition, which is a bit more complex, is generally described as Vestibular dysfunction. This is basically when the vestibular system is no longer working well; this can be due to problems withing one or many of the structures involved within this system. Now this can occur in both sides, but typically one side of the vestibular system will be stronger, so the information you are receiving about your movements will still be inaccurate; there will be an imbalance between the feedback you are receiving from both sides, which will cause symptoms of dizziness or moving when you are not.
 
With this condition, people may not always have vertigo episodes, but may tend to feel a baseline sensation of dizziness, a sensation of swaying or that they are always moving, or even that they are being pushed toward one side. With these conditions, people will always have a problem with combined movements of the head and eyes.
 
A vestibular loss like this can be due to certain medications over time actually leading to dysfunction of the vestibular system. Some of these medications may actually be meant to treat dizziness, but because it suppresses the vestibular system it can actually lead to it not working as well. Small tumors within the nerve that works with the vestibular system, known as the acoustic nerve, will also affect vestibular function. There are also certain viruses or ear infections that can cause inflammation of this nerve which will also produce vestibular symptoms. And also surgeries; for example, if someone has surgery to remove a tumor of the acoustic nerve, or even have a cochlear implant for hearing loss, may have vestibular dysfunction afterward.
 
The symptoms of dizziness and vertigo alone is very bothersome because of how unpleasant it is, and at times can be so severe that it can make someone feel nauseous or even lead to vomiting because of how strong the symptoms can be. It can interfere with your ability to perform simple movements such as turning your head, laying down, walking, turning your body, because many of these movements will reproduce those symptoms. And we need these movements to function, for example to drive, to turn our head while walking to look at something, just to perform our everyday tasks. Walking and standing can also be difficulty because your sense of stability and balance will also be affected. This is important to consider when we talk about balance and the risk for falls, for everyone but particularly in the elderly population, in which Dizziness is a risk factor for falls in older individuals
 
According to the CDC, 1 in 4 older adults fall every year. That is a big problem, because falls are also the leading cause of fatal and nonfatal injuries among this population. Broken hips and wrists, head injuries are all a big risk and something we should really worry about as we get older. Not only that, but another issue that tends to occur is immobility, because something that we tend to do when we experience something unpleasant is we try to avoid the specific movements that trigger the symptoms. In these cases, people will avoid turning or moving their head, limit their walking, may avoid laying down in certain positions, which then creates other problems, such as stiffness, muscle tightness, weakness, limited endurance, and sometimes even pain.
 
We as physical therapists, can help patients with these problems depending on the type of  vestibular disorder. So first of all we will do a complete evaluation of all the systems that are involved in balance, including your vestibular system. The Physical Therapist will then develop a Plan of Care that will address the specific impairments to help reduce symptoms, help teach the patient certain movements and exercises to help manage their symptoms, and of course help improve balance. Typically, this can include:
-       Gaze stability exercises, where we work on combining and coordinating eye and head movements
-       Repositioning maneuvers, specifically for BPPV, in which we have to move the head and the body through a series of positions to help move those crystals that we mentioned earlier, out of the canals and back to where they are supposed to be.
-       Adaptation, Substitution, and Habituation exercises – these are just concepts utilized more for vestibular loss, all they basically emphasize on the ability of the body to adapt over time, to adapt to repeated exposure to activities that tend to aggravate symptoms, and strengthening the other systems in the body to make up for the impaired vestibular system.
-       Balance training and fall prevention strategies
-       Gait training, where we may work on walking mechanics
-       Strengthening, flexibility, and proprioception exercises, not only as they play a role with balance and stability, but also because we have to address the secondary effects of becoming more sedentary or avoiding movements because of the symptoms
-       Functional activities for return to previous level of ability
 
It is important to continue to address balance difficulties, even after someone begins to have less symptoms with therapy, this goes back to being able to return to previous activities and ability to function. Similar to when people begin to experience less pain with certain treatment interventions, we want to make sure that the individual can safely and confidently return to the activities they were doing previously to improve their ability to function from day to day, and improve overall quality of life.
 
If you or someone you know has problems with their balance, or has questions, reach out to us and we will gladly talk to you or bring you in, so we can take a look at balance, we can test it and see how you are doing and we will figure out together what we need to do.
 

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