People with vestibular disorders often experience problems with vertigo (sense of false motion or spinning), dizziness, visual disturbance, and/or imbalance. Additionally, nausea, vomiting, reduced ability to focus or concentrate, and fatigue may occur secondary to a vestibular disorder. Symptoms caused by a vestibular disorder can interfere with quality of life and contribute to feelings of anxiety and depression. The purpose of Vestibular Rehabilitation is to reduce symptoms and improve quality of life.

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Vestibular Physical Therapy Assessment Includes

  • Vestibular and oculomotor function
  • Dizziness, balance, gait, and coordination
  • Winchester Clinic augments assessment with Insight Infrared Video Goggles for optimal observation of abnormal eye movements that can cause the sensation of vertigo. Visualizing these eye movements also aids in the diagnosis of vestibular conditions.

Evidence Based Treatment

Vestibular Facts

  • The prevalence of vestibular dysfunction in the US for adults over 40 is 35.4% (Agrawal et al 2009).
  • 10% of the Geriatric population was found to have unrecognized BPPV (Oghalai et al 2000).
  • People with BPPV often do not describe “spinning”, but instead dizziness, imbalance or feeling off.
  • Why choose PT for treatment of BPPV? 16% of BPPV treatment maneuvers lead to canal conversion (Foster et al 2012) which can make symptoms worse rather than better. This demonstrates the need for skilled assessment and skilled, guided treatment of BPPV to minimize complications.
  • Older adults with unrecognized BPPV are more likely to have reduced activity of daily living scores, depression and falls (Oghali et al 2000).
  • 55% of patients with BPPV reported a fall (vestibular registry, Grove, 2022).
  • Treatment of BPPV reduces falls in older adults (Jumani, 2017).

Possible Vestibular Symptoms

These can be symptoms of inner ear or central nervous system disorders.

  • Vertigo: Sense of false motion or spinning
  • Dizziness
  • Wooziness
  • Lightheadedness or feeling faint
  • Floating sensation
  • Nausea, vomiting
  • Feeling off balance, falls
  • Feeling rocking, tilted or pushed
  • Staggering
  • Blurred vision with head movements
  • Bouncy vision
  • Confusion or disorientation
  • Hearing loss or change
  • Noise/ringing in ear
  • Fullness, pressure in ear
  • Headache/migraine
  • Brain fog
  • Sensitivity to light, sound, smell
  • Neck pain
Eyetest

Common Conditions Treated

Benign Paroxysmal Positional Vertigo (BPPV)

BPPV is the most common cause of dizziness. It is an inner ear problem that accounts for 20-30% of all adult cases of dizziness and as many as 50% of cases in individuals over 65 years of age. The most common symptoms include brief episodes of vertigo (sense of spinning or false movement), dizziness, or unsteadiness, usually lasting less than one minute. You may also experience nausea, vomiting, sweating, and abnormal eye movements. These symptoms are brought on by positional changes of the head with respect to gravity. The most common symptom triggers include lying down/sitting up, rolling over, looking up, and bending over.

Causes

BPPV occurs when small crystals of calcium carbonate (otoconia) in the inner ear become displaced and fall into another part of the inner ear called the semicircular canals. The semicircular canals are fluid filled structures that sense rotational head movements. When otoconia crystals are free floating in the fluid of the semicircular canals, the fluid will move excessively when the head is moved relative to gravity. This abnormal movement of the fluid causes the sense of vertigo.

Evaluation and Treatment

Your physical therapist will evaluate you for BPPV using evidence based methods. If you have BPPV, your symptoms will be reproduced by this test. Your physical therapist may use video infrared goggles in order to see your eyes better during this test.

If you are found to have BPPV, treatment involves taking your head and body through a specific series of positions in order to move the crystals back out of the inner ear canals. This is called a Canalith Repositioning Maneuver. The most common Canalith Repositioning Maneuver is the Epley Maneuver. Canalith repositioning may be repeated 1-3 times in a session to maximize the success of the treatment.

Eighty percent of people get relief from one treatment session for typical BPPV (Gordon and Gadoth 2004). However, additional sessions may be required.

Recurrence

BPPV can recur. If your BPPV does return, you should contact your physical therapist. With a recurrence the crystals may be in a different canal, so your treatment may be different than before. You should never try to use internet videos to attempt to treat yourself. If appropriate, your physical therapist may teach you exercises to perform at home for treatment and prevention. However, this is not appropriate in all cases. Medication (Meclizine, Antivert, Dramamine) has not been proven effective but rather can cause more harm than benefit.

Remember, BPPV is treatable and the repositioning maneuvers can greatly reduce your vertigo and other symptoms associated with BPPV.

Risk factors for BPPV:

  • Age
  • Female
  • Low vitamin D
  • Osteoporosis/Osteopenia
  • Diabetes
  • High cholesterol
  • High blood pressure
  • Falls/blow to head/concussion

Once BPPV is resolved it is not unusual to have some residual motion sensitivity and/or balance impairments which can be addressed by Physical Therapy.

Unilateral Vestibular Hypofunction

The inner ear contains a vestibular organ supplied by a vestibular nerve. Together they make up the peripheral vestibular system. This system sends information about balance, head position, and head movement to the brain. The right and left peripheral vestibular systems normally work equally and opposite of each other. Unilateral Vestibular Hypofunction occurs when one side is not working normally, due to damage or irritation of the vestibular nerve. The imbalance in function causes the brain to receive conflicting information. This conflicting information causes you to be symptomatic.

Symptoms

Symptoms of Unilateral Vestibular Hypofunction include a gradual onset of dizziness or vertigo, nausea and vomiting. These symptoms usually peak within 24 hours, but severe symptoms may remain for 2-4 days. Other symptoms may include:

  • Hearing loss, temporary or permanent
  • Imbalance, especially with head turns
  • Sensitivity to head movements
  • Motion sensitivity
  • Trouble walking, especially outdoors, in dark rooms, or in crowded places
  • Blurred vision, especially when turning your head quickly
  • Tinnitus (ringing in the ear)

Cause

Any process that causes irritation or damage to the vestibular nerve or vestibular organ in the inner ear can lead to vestibular hypofunction. Causes may include:

  • Bacterial or viral infection resulting in Vestibular Neuritis (Neuronitis) or Labyrinthitis
  • Age related changes to the structures of the inner ear
  • Impaired blood flow to the inner ear
  • Toxic reaction to medications administered in the ear

Treatment

Medical Providers may prescribe antibiotics or medications to help decrease the dizziness and nausea, and steroids to minimize hearing loss. Some individuals with Unilateral Vestibular Hypofunction caused by infection have complete resolution of symptoms when the infection clears. Others have residual symptoms.

Vestibular rehabilitation is a specific type of Physical or Occupational Therapy aimed at helping your body and brain to adapt and compensate for imbalance in vestibular function. Vestibular rehabilitation will usually involve a combination of eye exercises (gaze stabilization), motion exercises, balance exercises, and walking exercises to help with this process, thus decreasing your symptoms. Your exercise program will be reviewed and modified frequently to aid with the recovery process. Completion of your home exercise program is crucial for your successful recovery. These exercises should be challenging and will cause some symptoms. Mild symptoms are necessary to help your body and brain adapt and compensate. Severe symptoms, however, are not necessary. Symptoms that occur due to your home exercise program should decrease within approximately 30 minutes of completing your exercises.

Other Vestibular and Associated Conditions

  • Motion sensitivity
  • Visual motion sensitivity
  • Cervicogenic dizziness
  • Concussion
  • Vestibular migraine
  • Imbalance
  • Fall risk

FAQs

How will physical therapy help my vestibular issue?

  • Physical Therapy can help a variety of vestibular related diagnoses and issues such as BPPV, gaze instability, balance, dizziness, motion sensitivity, visual motion sensitivity, walking, and motion sickness.
  • Our physical therapists have advanced training in the management of vestibular disorders, and we utilize infrared video goggles to better visualize eye movements to aid in our assessment.
  • Vestibular Physical Therapy cannot help hearing loss or tinnitus (ringing in the ear).

Why are there two parts to the initial testing?

  • Our PT sessions are 40 minute blocks. A full vestibular exam takes about 60-80 minutes.

What does the testing consist of?

  • The exam will include time to discuss your particular history and symptoms, screening your heart rate and blood pressure, exam of vestibular and oculomotor function, testing for BPPV, and assessment of Balance and walking. Other examination may be indicated based on your specific symptoms and challenges.

Will the initial appointment make me dizzy or nauseous?

  • We may need to provoke your symptoms to determine what is causing them. However, we monitor your symptom provocation closely and minimize it as much as possible. If you tend to feel nausea with your symptomatic episodes, you may feel that during some exam procedures. However, vomiting is rare.

Should I take my dizziness/nausea medication prior to coming?

  • In most cases dizziness medication (Meclizine, Antivert, Dramamine) is prescribed for use “as needed”. If this is the case, unless you require your dizziness medication to function (ie, get out of bed and walk around your home), it is best not to take it the day of your appointment. If you have been vomiting or severely nauseated with your dizziness, then it may be best to take it before coming. If medication has been prescribed for you, and helps your symptoms, please feel free to bring it with you, so you can take it at the conclusion of your exam if needed.

Do I need a referral from my doctor before starting therapy?

  • In the state of Virginia, a doctor’s referral/prescription is not required for participation in PT. However, if you have one, please bring it with you. Either way, we will send our findings to your referring provider or primary care provider.

When will I start seeing results or feeling better?

  • This will depend on what is actually causing your symptoms. BPPV can often be resolved in 1-4 treatment sessions, but there may be some mild residual motion sensitivity and imbalance that would benefit from a few weeks of PT. For other causes of vestibular symptoms you may start feeling better in 1-2 weeks but should expect the full course of PT treatment to last 4-12 weeks.

Physical Therapy Treatments for Vertigo, Inner Ear Conditions, Dizziness & Balance.

Feeling dizzy can make it difficult to participate in daily activities.
Fortunately, physical therapy may reduce many of the uncomfortable sensations associated with vertigo,
dizziness, and balance disorders. Our certified doctors of physical therapy are ready to help you regain mobility and feel your best.

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