Dizziness and Motion Sensitivity

Motion Sensitivity Testing in a Vestibular Rehabilitation Assessment

Finding the movements that make you dizzy helps vestibular rehab professionals to tailor your exercise program

How Do We Measure Dizziness?

Dizziness is very subjective, making it difficult to measure.   In an attempt to quantify it and to be able to record improvement over time, one of the things often done in a Vestibular Rehabilitation assessment is called Motion Sensitivity Testing.  This involves a series of movements or position changes, where a person rates their dizziness after the movement on a 0-5 scale, and we compare that to the person’s baseline rating prior to the movement.  We also measure the length of time it takes to return to baseline after each movement.  These numbers can be calculated into a final Motion Sensitivity Quotient, and tracked over time. The movements are just one at a time, with a rest after each one to allow your symptoms to settle back down, so most people tolerate the testing well.  If too provoking, we would just modify the test or wait until later for testing when your dizziness is not so strong.

Finding the movements that make you mildly or moderately dizzy helps us to tailor a vestibular rehabilitation exercise program to your individual needs, as the brain needs to be exposed to these types of movements in order to be able to compensate for a vestibular imbalance.  With controlled exposure to the movements that make you dizzy, the brain can begin to habituate so that the movement becomes less and less bothersome.  Reduction in the intensity and/or duration of your motion-provoked symptoms is a good indicator that your vestibular rehabilitation exercises are helping you improve.

Should You Avoid the Motions That Make You Dizzy?

Research shows that avoiding exposure to the movements that trigger the error signals and make you dizzy actually delays recovery. The brain needs to see these mismatched signals in order to come up with strategies to adapt and compensate.  The mismatched vestibular signals may still be there, but in most cases the brain can make adjustments so that you don’t feel the symptoms anymore through a process called Habituation.

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Diagnosing Vestibular Problems

What Do We Test for in a Clinical Evaluation of Dizziness?

Before going into actual vestibular tests, it is important that Vestibular Rehabilitation Therapists take a thorough history and perform some safety checks to make sure that your dizziness is not potentially due to something that should be looked after by a Doctor.

When we ask about your history, we will want to know things like:

• When your symptoms started;
• Whether they were insidious ("out of the blue") or related to an incident or illness;
• If there were other symptoms than just dizziness, i.e. nausea/vomiting, hearing changes, vision changes, headache, numbness/"pins and needles", unsteadiness;
• The nature of your initial and current dizziness, i.e. lightheadedness, disorientation, feeling "off", "room spinning";
• The duration of your initial and current symptoms: seconds, minutes, hours, days;
• What increases or decreases your symptoms, if anything;
• Other medical conditions you are dealing with, medications, previous experiences with dizziness and family history.

Safety Checks in Initial Dizziness Screening Help to Identify any Medical Concerns

The safety checks we perform in our initial screening include:

1. Checking the mobility of your neck, and, if there has been trauma or rheumatoid arthritis, stability of the ligaments in the upper part of the neck;
2. Checking if certain neck positions produce signs or symptoms suggesting compromise of the blood flow through the neck to the head;
3. Performing tests to see if some of the control centers in your brain (cranial nerves and cerebellum) appear to be working properly;
4. If indicated by your history, blood pressure testing including a comparison between lying down and standing.

If there are concerns from your history or the testing above that your Doctor is not aware of and has not investigated, we would refer you back to your Doctor for further testing. In some instances we would put further testing and treatment on hold until your Doctor has seen you, and in other cases, we can proceed while you are awaiting further work-up by your Doctor.

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How the Inner Ear Can Become Damaged

Side Effects of Medication Can Result in Vestibular Problems

Medication can sometimes cause vestibular problems

The vestibular system, which includes the inner ear, is where the body handles balance and detects motion.  In rare occasions the inner ear can be adversely affected by certain medications.  In the case described in this CBC article, taking medication resulted in the destruction of a part of a patient’s vestibular system.   In addition to some antibiotics like gentamicin, referred to in this article, other medications that can be destructive to the inner ear (“ototoxic”) include certain cancer drugs, like cisplatin, and some quinine derivatives like mefloquine, used for malaria prevention.  Several other medications seem to be toxic to the hair cells in the hearing part of the inner ear, but not necessarily the vestibular/balance part.  Susceptibility can be increased in those who have problems with renal (kidney) function, which would normally help clear the medications from one’s system.

Damage to the Inner Ear Can Happen in a Multitude of Ways

Astronauts at space stations can suffer from vestibular problems

In addition to certain medications, there are many other ways that the inner ear can become damaged, like through inner ear infections, genetics, environmental chemicals, stroke or head trauma, to name just a few.

Another example of information from the inner ear being out of sync with information with the eyes is in the case of astronauts who spend extended periods of time at Space Stations. “Chris Hadfield acknowledged that life back on Earth, after five months of living on the International Space Station, came with dizziness and motion disturbances.” (CBC)

Damage can also be a result of certain professions like sound engineers and military personnel who are exposed to loud sounds, although this generally affects the hearing part of the inner ear as opposed to the balance part.  Contact sports players who sustain concussions can sustain damage to either part, like Sidney Crosby who developed chronic vertigo from having a series of vestibular concussions.

Why Are Vestibular Problems Not Taken Seriously, When So Many Canadians Suffer From Them?

The National Institute on Deafness and other Communication Disorders reports that approximately five per cent of Americans (roughly 15 million people) suffer from chronic vestibular problems. In Canada the number of people suffering from chronic vestibular damage is estimated to be around 1.5 million people.

According to an inner ear expert, dizziness and vertigo are two of the fastest growing health search terms on Google. David Pothier of Toronto’s University Health Network, in an inner ear specialist and researcher, indicates that “vestibular patients are often not taken seriously”. (CBC) The norm is that patients can spend up to two years in the health care system looking for the right care before they are properly diagnosed and receive the right care.  Having a clinical evaluation of dizziness to explore vestibular problems is one way to help ensure that vertigo is diagnosed properly.

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What is the Epley Maneuver?

How Vestibular Rehabilitation Therapists Use Canalith Repositioning Maneuvers (i.e. the Epley Maneuver) to Correct BPPV

There are many different treatments that vestibular rehabilitation therapists can provide to help with a wide variety of vestibular problems. One type of treatment includes performing maneuvers to correct Benign Paroxysmal Positional Vertigo (BPPV) which is one of the most common causes of brief vertigo or 'room spinning'.

The Epley Maneuver is a Specific Series of Head Positions Performed by a Medical Professional

A person suffering from BPPV will normally find that moving their head into certain positions causes brief vertigo, lasting about 30 seconds.  This is because otoliths (calcium carbonate crystals) that are no longer in the correct part of the inner ear, move with gravity and deflect hair cells which stimulate nerves to send false movement signals to the brain.  In maneuvers like the Epley Maneuver a medical professional moves your head slowly and carefully through a very specific series of positions.  This allows gravity to move the calcium carbonate crystals (otoconia) out of the part of the inner ear where they are not supposed to be, back into a place in the inner ear where they’ll no longer cause false signals and debilitating symptoms like vertigo. (Vestibular Disorders Association - VEDA)

It is very important to understand, however, that the Epley maneuver is only one of numerous canalith repositioning maneuvers and will ONLY work for certain variants of BPPV.  It is normally highly effective for the most common form of BPPV but if it isn’t working perhaps you have a different type of BPPV requiring a different maneuver, the maneuver isn’t being performed correctly, or maybe you don’t actually have BPPV at all.

Don't Try the Epley Maneuver By Yourself

Despite instructions being readily available on the internet, it is advisable to avoid performing the Epley maneuver on your own in most circumstances.  It is important for the diagnosis of BPPV to be confirmed by a medical professional who is specifically trained to do so, and they can also determine whether a patient is a candidate for a canalith repositioning procedure based on mobility and other medical conditions.  They can determine which variant of BPPV you have, which then dictates if the Epley maneuver is the appropriate treatment or whether a different canalith repositioning maneuver is required.   They would then proceed with helping you through the appropriate maneuver, so doing it on your own shouldn’t be required.  If the treatment isn’t immediately effective, the professional can help screen for other medical conditions that might make self-treatment unadvisable, and if deemed safe, they may teach you to do the maneuver on your own, however it is still recommended to do this under medical supervision instead for safety and effectiveness.

How Many Times Does It Take Before the Epley Maneuver Works?

According to the Vestibular Disorders Association, canalith repositioning procedures (like the Epley Maneuver) are very effective for BPPV, with an approximate cure rate of 80% and low recurrence rate (VEDA).  BPPV as the result of trauma may require more treatments to correct, however most people require just one treatment.  The vast majority of cases are corrected by 3 treatments, so if it seems to be requiring more, the following questions need to be asked:  Has the BPPV variant been identified correctly? Has the appropriate canalith repositioning maneuver been chosen?  Is it being performed correctly? And, could this be something other than BPPV?  A medical professional well-trained in vestibular disorders can help answer these questions.

Read about why it is so important to treat dizziness.

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Decreased Medical Clearance Time with Cervicovestibular Rehabilitation After Sports-Related Concussion: Trial

Many Common Symptoms Between Concussion and Neck/Vestibular Injuries

In sports, a concussion is a common injury from which individuals usually recover in 7-10 days. But for athletes whose symptoms persist beyond that point, it is not always clear whether a neck injury is involved and whether the vestibular (balance) system has been affected. Many of the same symptoms are common to concussions and to injuries to the neck and/or balance system known as cervical/vestibular injuries. These include dizziness, unsteadiness, neck pain and/or headaches following a sport-related concussion.

Trial Studies Whether Combined Vestibular Rehab and Cervical Spine Physio Decreases Post-Concussion Recovery Time

In the June 2014 randomized controlled trial "Cervicovestibular Rehabilitation in Sport-Related Concussion", the objective was to determine if a combination of vestibular rehabilitation and cervical spine physiotherapy would decrease the time until individuals with prolonged post-concussion symptoms received medical clearance.

The trial concluded that the combination of cervical and vestibular physiotherapy did significantly decrease the time that youth and young adults who had sustained a sport-related concussion and suffered from persistent symptoms of dizziness, neck pain and/or headaches, were medically cleared to return to their sport. Evidence suggests that a combined approach to treatment of the cervical spine and vestibular systems may facilitate recovery and decrease time lost from sport in individuals with persistent symptoms. Future research is expected to evaluate the optimal timing of treatment and the effects of covariates such as age, history of concussion and dosage.

The trial was conducted by Drs. Kathryn J. Schneider, Willem J. Meeuwise, Alberto Nettel-Aguirre, Karen Barlow, Lara Boyd, Jian Kang and Carolyn A. Emery at the University of Calgary.

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Vestibular Treatment for Concussion Management

Combined Vestibular & Cervical Spine Physiotherapies for Concussion Management Produces Positive Results

When concussion management includes treatment of the vestibular system combined with treatment of the cervical spine, athletes are four times more likely to return to their sport within eight weeks, according to a study conducted by Dr. Kathryn Schneider, a researcher with the Sport Injury Prevention Research Centre at University of Calgary's Faculty of Kinesiology.

Dr. Schneider was both a Vestibular Physiotherapist and an Orthopedic Manual Physiotherapist at LifeMark Health for many years in Calgary before accepting the position of Assistant Professor/Clinician Scientist in Concussion, Faculty of Kinesiology, at the University of Calgary. She has long felt that her concussion patients responded well to treatment of their necks and of their often overlooked vestibular system, so it was exciting to see the research confirm this so convincingly.

High Success Proves Effectiveness of Vestibular Rehabilitation & Cervical Spine Physiotherapy

A Globe and Mail article describing this innovative concussion treatment describes the study. "Thirty-one people between the ages of 12 and 30 (18 males and 13 females), all of them having suffered a sports-related concussion, took part in the study and were split into two groups. Some patients were given a postural education on how to it and stand along with range-of-motion exercises and gradual exertion in their efforts to return to their sport as soon as possible. Others received vestibular rehabilitation plus cervical spine physiotherapy.

The results were utterly one-sided. Of the 15 patients who had the combination vestibular and neck therapy, 11 were medically cleared before or by eight weeks, a 73 per cent success rate. For patients who didn't receive the therapy, only four per cent were considered healthy enough to play again.

Dr. Schneider spent more than a year studying and documenting people who suffered from prolonged post-concussion symptoms such a dizziness, neck pain and headaches. For treatment of cervical spine symptoms involving patients' vertebrae, soft tissues, mobility, strength and posture in the neck, orthopedic Physiotherapy techniques were used. For treatment of vestibular/inner ear dizzines and/or balance issues, she used a variety of different techniques. Some of these included stationary and moving balance work on different surfaces, exercises to coordinate neck muscles and eyes, maintaining focus during head motion, catching a ball while walking, and when indicated, a series of head movements to correct the position of crystals in the inner ear that can sometimes get dislodged with trauma (a condition called BPPV).

At LifeMark Health, we have benefitted from ongoing education provided by Dr. Schneider over many years. Most of our Vestibular Physiotherapists are also Orthopedic Physiotherapists and know how to combine these two types of care in helping our concussion clients recover as quickly as possible.

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Balance Awareness Week is September 15-21, 2014