Treatment

Evidence has shown that vestibular rehabilitation can be effective in improving symptoms related to many vestibular (inner ear/balance) disorders (McDonnell & Hillier, 2015). People with vestibular disorders often experience problems with vertigo, dizziness, visual disturbance, and/or imbalance. These are the problems that rehabilitation aims to address.

Ways to achieve this include:

Vestibular rehabilitation exercises
Educating the patient about their condition
Promoting maintenance of general fitness; this can be done simply by asking the patient to go for walks daily
Prescription of gait aids if indicated
Referral/s to other health professionals if indicated

The goal of vestibular rehabilitation is to use a problem-oriented approach to promote compensation. This is achieved by customizing exercises to address each person’s specific problem(s). Therefore, before an exercise program can be designed, a comprehensive clinical examination is needed to identify problems related to the vestibular disorder. Depending on the vestibular-related problem(s) identified, three principal methods of exercise can be prescribed: 1) Habituation, 2) Gaze Stabilization, and/or 3) Balance Training (Herdman & Clendaniel, 2014).

Habituation:

Habituation exercises are used to treat symptoms of dizziness that are produced because of self-motion (Shepard and Telian, 1995) and/or produced because of visual stimuli (Pavlou et al., 2004; Pavlou et al., 2011). Habituation exercise is indicated for patients who report increased dizziness when they move around, especially when they make quick head movements, or when they change positions like when they bend over or look up to reach above their heads. Also, habituation exercise is appropriate for patients who report increased dizziness in visually stimulating environments, like shopping malls and grocery stores, when watching action movies or T.V., and/or when walking over patterned surfaces or shiny floors.

Habituation exercise is not suited for dizziness symptoms that are spontaneous in nature and do not worsen because of head motion or visual stimuli. The goal of habituation exercise is to reduce the dizziness through repeated exposure to specific movements or visual stimuli that provoke patients’ dizziness. These exercises are designed to mildly, or at the most moderately, provoke the patients’ symptoms of dizziness. The increase in symptoms should only be temporary, and before continuing onto other exercises or tasks the symptoms should return completely to the baseline level. Over time and with good compliance and perseverance, the intensity of the patient’s dizziness will decrease as the brain learns to ignore the abnormal signals it is receiving from the inner ear (Farrell, 2015).

Gaze Stabilization:

Gaze Stabilization exercises are used to improve control of eye movements so vision can be clear during head movement. These exercises are appropriate for patients who report problems seeing clearly because their visual world appears to bounce or jump around, such as when reading or when trying to identify objects in the environment, especially when moving about.

There are two types of eye and head exercises used to promote gaze stability. The choice of which exercise(s) to use depends on the type of vestibular disorder and extent of the disorder. One type of gaze stability exercise incorporates fixating on an object while patients repeatedly move their heads back and forth or up and down for up to a couple of minutes (Farrell, 2015). The following pictures demonstrate examples of this type of gaze stability exercise.

(Farrell, 2015)

The other type of gaze stability exercise is designed to use vision and somatosensation (body sense) as substitutes for the damaged vestibular system. Gaze shifting and remembered target exercises use sensory substitution to promote gaze stability. These exercised are particularly helpful for patients with poor to no vestibular function, such as patients with bilateral (both sides) inner ear damage (Herdman & Clendaniel, 2014).

Balance Training:

Balance Training exercises are used to improve steadiness so that daily activities for self-care, work, and leisure can be performed successfully. Exercises used to improve balance should be designed to address each patient’s specific underlying balance problem(s) (Horak, 2006). Also, the exercises need to be moderately challenging but safe enough so patients do not fall while doing them. Features of the balance exercises that are manipulated to make them challenging, include:

Visual and/or somatosensory cues
Stationary positions and dynamic movements
Coordinated movement strategies (movements from ankles, hips, or a combination of both)
Dual tasks (performing a task while balancing)

Additionally, balance exercises should be designed to reduce environmental barriers and fall risk. For example, the exercises should help improve patients’ ability to walk outside on uneven ground or walk in the dark. Ultimately, balance training exercises are designed to help improve standing, bending, reaching, turning, walking, and if required, other more demanding activities like running, so that patients can safely and confidently return to their daily activities.

For patients with Benign Paroxysmal Positional Vertigo (BPPV) the exercise methods described above are not appropriate. Fortunately, there a several other techniques that can be used to treat BPPV.

Epley Manoeuvre:

The Epley manoeuvre is used to treat benign paroxysmal positional vertigo (BPPV) of the posterior or anterior canals (Hilton & Pinder, 2004). It works by allowing free floating particles from the affected semicircular canal to be relocated, using gravity, back into the utricle, where they can no longer stimulate the cupula, therefore relieving the patient of bothersome vertigo (Prokopakis et al., 2005; Wolf, Boyev, Manokey, & Mattox, 1999).

Epley's

Procedure:

1. The patient begins in an upright sitting posture, with the legs fully extended and the head rotated 45 degrees towards the side in the same direction that gives a positive Dix–Hallpike test. Place pillow behind patient so that on lying it will be under the patient’s shoulders.

2. The patient is then quickly and passively forced down backwards by the clinician performing the treatment into a supine position with the head held approximately in a 30-degree neck extension (Dix-Hallpike position), and still rotated to 45 degrees. The patient remains in this position for 30 seconds.

3. The patient's head is then rotated 90 degrees to the opposite direction so that the opposite ear faces the floor, all while maintaining the 30-degree neck extension. The patient remains in this position for 30 seconds.

4. Keeping the head and neck in a fixed position relative to the body, the individual rolls onto their shoulder, rotating the head another 90 degrees in the direction that they are facing. The patient is now looking downwards at a 45-degree angle. The patient remains in this position for 30 seconds.

5. Finally, the patient is slowly brought up to an upright sitting posture, while maintaining the 45-degree rotation of the head. The patient holds sitting position for up to 30 seconds.

(Owen-Michaane, 2015)

The entire procedure may be repeated two more times, for a total of three times.

The diagram below shows the movement of particles in the semicircular canal during each stage of the Epley manoeuvre.

(Laquindanum, 2014)

If appropriate, patient’s can also be taught how to perform the Epley manoeuvre by themselves at home. In this case, a hand-out similar to the one below should be provided.

How To Do The Modified Epley Manoeuvre For The Right Ear

(Owen-Michaane, 2015)

Brandt-Daroff:

Brandt Daroff exercises are another method that can be used to treat benign paroxysmal positional vertigo. These exercises are designed to break up this material and unblock the canal.

Procedure:

1. Patient sits on the edge of a bed and turns their head slightly to the left (approximately 45 degrees).

2. While maintaining this head position, the patient lies down quickly on their right side so that the back of their head is resting on the bed. Wait for 20 to 30 seconds or for any symptoms to resolve.

3. Patient sits up straight, and again waits for 20 to 30 seconds or for any symptoms to resolve.

4. Patient turns their head slightly to the right and repeats the sequence in the opposite direction.

Continue as above for 10 minutes (5 or more repetitions to each side). Perform the exercises 3 times daily if possible.

Brandt-Daroff

(Sandwell and West Birmingham Hospitals, 2012)

After BPPV has been successfully treated and spinning symptoms resolved, some patients will continue to report non-specific dizziness (symptoms other than spinning) and/or imbalance. In these cases, treatment using habituation exercise and/or balance training may be indicated (Herdman & Clendaniel, 2014).