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.

Feel free to contact us – we are here to help you!

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.

Contact us to find a vestibular therapist near you.

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.

Contact us to find a vestibular therapist near you.

Balance Awareness Week is September 15-21, 2014

Summer Challenges for Vestibular Patients

By Sheelah Woodhouse, P.T., BScPT National Director of Vestibular Rehabilitation for LifeMark & Centric Health | Certified Vestibular Therapist | President, Vestibular Disorders Association

Summertime, and the Living is Not So Easy... If You Have a Vestibular Disorder

Summertime conjures up images of getting outside, traveling, going to social gatherings, having a few drinks on the patio. This all sounds great to most people but if you have a vestibular disorder, there are a lot of elements in these activities that can be a real challenge and can make symptoms worse.

Dizziness Symptoms and the Great Outdoors

First of all, let's look at getting into the great outdoors. Those with vestibular problems can't use the information from their inner ear(s) about balance and orientation as well as they used to. Therefore, they are typically more dependent on the position information they get from their feet and ankles than the rest of us. Walking on surfaces that are not hard and flat spells trouble (!), so walking on the soft grass, sand, or unpaved trails can create unsteadiness and fear of falling.

Balance Challenges on a Plane or Boat

How about travelling? Being on a plane or boat can also be very challenging for those with vestibular problems, again because the information they are getting from the muscles and joints in their bodies is no longer the same as what they get when on solid ground.  These forms of travel also create a mismatch in the balance system because the things on the boat or plane that you are looking at suggest that you are stationary because they are moving the same as you, yet your body and your inner ears sense that there is in fact some motion taking place.  Usually the inner ear/vestibular system would step in to sort out this conflict, but if that isn’t working properly, people can start to feel quite disoriented and unwell.  Looking out of the plane or boat rather than at items inside can be helpful so that your eyes can see that there is some movement taking place, and then can agree with your body and inner ears.

Vestibular Disorders and Visual Cues

Well then let’s just drive to the lake.  Driving in a car can create the same scenario as above, especially if sitting in the back seat which makes you more likely to be looking at things inside the car than outside.   Just like being more dependent on reliable cues from the ground, those with vestibular disorders are also more dependent on the information about orientation that they get from vision.  When that is the case, people can get quite stirred up by visual stimulation: the sunlight flickering through the trees, the motion of other vehicles around them, all the scenery going by.  And once you get to the lake, even just watching the movement of the water can be quite disorienting and disturbing.

OK well then let’s just stay home and visit with friends and family.  Sounds promising, but at social gatherings where there is the visual stimulation of people milling about, a lot of standing instead of sitting, head turning as you talk to this person and that, this can be a provoking option as well.  Add in spongy flip-flops or those great strappy shoes with a bit of a heel, and a few drinks, and those with vestibular disorders often don’t do well here either.

Education, Pacing, Strategic Choices and Appropriate Treatment all Help Vestibular Disorders

All is not lost!  With education, pacing, strategic choices and appropriate treatment, those with vestibular disorders can reduce and manage their symptoms and enjoy life!  See: http://vestibular.org/living-vestibular-disorder/everyday-challenges#travel   for tips.  Hopefully the scenarios described above can help those without these disorders appreciate the hidden challenges that those with vestibular problems are trying to work around, and offer their understanding and assistance.

Contact us at lifemarkvestibular.ca - we can help!

What Keeps Us in Balance?

How Input From Muscles and Joints Affects Our Balance

Just as a baby first learns how to balance by practicing and repeating certain movements, each of us adjusts to changing environments or health conditions throughout our lives to keep our balance. But how do our muscles and joints play into this?

Balance Maintained by Our Complex Sensorimotor Control Systems

Our balance is maintained by complex sensorimotor control systems all working together, and if one of these systems is upset or not working properly, we can lose balance. The three main systems of the body that provide sensory information to keep us in balance are vision, the vestibular system (inner ear) and the proprioceptive (or somatosensory) system.

It is the proprioceptive system that involves feedback to our brains from our muscles, joints and pressure sensors. This system has pressure and position sensors in the feet, trunk and spine. According to the Vestibular Disorders Association (VEDA), sensory information coming from our necks and ankles are the most important. "Proprioceptive clues from the neck indicate the neck indicate the direction in which the head is turned. Cues from the ankles indicate the body’s movement or sway relative to both the standing surface (floor or ground) and the quality of that surface (for example, hard, soft, slippery, or uneven).”

Information from muscles, joints and skin is produced from sensory receptors that react to pressure or stretching in tissues surrounding it in the body, telling our brains about our position in space.

How Does Motor Output Back to Our Muscles and Joints Affect Balance?

If we start tipping forward for example, the brain senses increased pressure in the front of the soles of our feet and our ankles bending.  The brain can then send instructions to the muscles along back of our body to keep us from tipping further forward and pull us back upright if we weren’t leaning forward on purpose.  The other two balance systems should help out with this reaction as well: the eyes should notice the forward sway relative to one’s surroundings and the inner ears should sense the forward tilt as well.

If one or more of these three systems is not working well, then the brain’s instructions to these antigravity muscles can be delayed or inaccurate, resulting in unsteadiness. Vestibular rehabilitation and balance training can help a person learn to compensate and improve their balance reactions by utilizing the remaining systems more effectively.

Contact us to find a vestibular therapist near you.

How Vestibular Rehabilitation Therapy Can Help With Ménière’s Disease

What Are the Symptoms of Ménière’s Disease?

Some people who are thought to have Ménière's Disease actually have a form of Migraine

According to the Vestibular Disorders Association (VEDA), symptoms of a Ménière’s Disease attack can vary between individuals as well as between different progressive stages of the attack as it occurs. Some people have a bit of a warning that an attack is coming, including dizziness, lightheadedness, unsteadiness and hearing change. However, as the attack gets going in earnest, there is typically ear fullness, ringing/roaring or loss of hearing, and spontaneous, violent vertigo, usually lasting for hours.

It should also be mentioned that some people who are thought to have Ménière’s Disease actually turn out to have a form of Migraine. Many of the symptoms can be very similar, hence the occasional misdiagnosis, and Migraine is far more prevalent than Ménière’s. You do not necessarily have to have a headache for it to be Vestibular Migraine but if you do have a headache or head pressure with your attacks, or notice disturbance to your visual field / sensitivity to visual stimuli like light or motion before your attacks, be sure to let your Family Doctor and Ear, Nose & Throat Doctor know.

What Causes Ménière’s Disease?

Although the exact cause is unknown, it is generally accepted that the symptoms result from what's called endolymphatic hydrops or "increased pressure of an abnormally large amount of endolymph [the fluid that fills the balance organ in our inner ears] in the inner ear and/or from the presence of potassium in an area of the inner ear where it doesn't belong." (VEDA).

Some of the theories proposed regarding the cause of Ménière’s Disease include an autoimmune reaction, a genetic connection, circulation problems, migraine, and a viral infection. Most of the adults who have Ménière’s Disease are between 40 and 60 years of age.

How Vestibular Rehab Can Help Those with Ménière’s Disease

Unfortunately, there is no "cure" for Ménière’s Disease. Some people with Ménière’s Disease return to feeling 100% between attacks, other than typically a progressive hearing loss. For those people, the role of the Vestibular Therapist is purely educational and Vestibular Rehabilitation is not needed. We can help the sufferer understand more about the condition and some dietary and lifestyle changes they might be able to try in order to reduce the frequency of the attacks.

For others, especially after repeated attacks, the function of the vestibular part of the inner ear does NOT bounce back to normal between attacks, and those people have ongoing symptoms. In addition to the education mentioned above, for these people we would provide a thorough assessment to identify what vestibular problems are persisting, then choose from the following vestibular rehabilitation techniques to help minimize their symptoms:

• Adaptation or gaze stabilization training to help with being able to focus clearly with head movement;
• Habituation techniques to reduce dizziness or sensitivity to movement;
• Static and dynamic balance training to reduce unsteadiness;
• Repositioning Maneuvers if a condition called BPPV has gotten triggered by the attack;
• Manual therapy on the neck to reduce the muscle tension and guarding of head movement that often follows an attack.

These techniques do not cure or prevent attacks, but can help people feel much better between attacks.

Contact us at http://www.lifemarkvestibular.ca - we can help!

Not All Vestibular Dizziness is from the Inner Ear

Problems Can Result from Central Vestibular Connections Within the Brain

The ears are for more than just hearing.  There is what’s called a vestibular apparatus in the inner ear that is for sensing our head positions and movements.  While problems with this part of the inner ear is a common source of dizziness, sometimes the vestibular problem is not because of the ear(s) at all but rather the central vestibular connections within the brain.

Inner Ear Information Sent to Processing Centers in the Brain in a Fraction of a Second

The vestibular part of the inner ear is just one piece of a whole vestibular system, and problems anywhere along the nerve pathways in this system can cause dizziness or balance problems.  Here’s how the system works:  The inner ears send their information about head movement/position in along nerves to the main vestibular processing centers in the brain called the vestibular nuclei.  With help from other parts of the brain, in particular the coordination center or cerebellum, the vestibular nuclei weigh out the information from the ears against each other, as well as against what your eyes are seeing and your body is feeling, in order to be really sure about what body position or movement is going on.  Once it has that figured out, the nuclei send instructions:

1. up to your eye muscles to tell the eyes how to move so that we can keep things in focus while the head is moving, and 
2. down your spinal cord to all the muscles that need to fire in order to keep us upright and balanced.

This all happens in a fraction of a second!  The vestibular reflexes are among the fastest in the body since, as you can imagine, being able to see clearly when moving and keeping one’s balance are so important for function and survival. 

The Vestibular System Involves Many Nerve Pathways & Many Parts of the Brain and Body

So as you can see, the vestibular system is a very complex one, involving many nerve pathways and many parts of the brain and body.  That being the case, there are lots of potential trouble spots that have nothing to do with the inner ears but are still vestibular-related.   The inner ear is the most common culprit when it comes to vestibular dizziness, however, some conditions that can affect the central vestibular pathways and connections within the brain include:

• Migraine
• Tumors
• Head Injury
• Multiple Sclerosis
• Vestibular Epilepsy
• Stroke
• Age or disease-related degeneration of brain tissue
• Or anything impairing the supply of blood, oxygen or glucose to parts of the brain

While we can often make some positive changes with Vestibular Rehabilitation for people with central (brain-related) vestibular problems, it often takes longer, and the outcomes are not as good as when the problem is with the inner ear.  However, people with only central vestibular issues have better outcomes than those with both central and ear-related problems.

Contact us at http://www.lifemarkvestibular.ca - we can help!

7 Things That Can Go Wrong With Vestibular Information From One Ear

What Happens When the Brain Gets Abnormal Information Coming From One Ear?

It can be confusing for the brain when one inner ear is telling a different story that the other inner ear is telling

When the brain receives information about movement or position from one ear that doesn't match the other ear, error signals alert you that something is wrong. Many different things can affect the vestibular information from one side, such as:

1. Ear infections
2. Vascular changes
3. Tumors
4. Perilymphatic Fistula (a small hole that can occur in the labyrinth)
5. A concussion or other trauma affecting only one labyrinth
6. Mechanical problems like BPPV. Benign Paroxysmal Positional Vertigo, which is common especially among older adults, is the most common cause of a false sensation of spinning (vertigo).
7. Alterations in fluid pressure in one labyrinth like Endolymphatic Hydrops/Meniere's disease

What Happens When Fluid Pressure Shifts in the Inner Ear?

With conditions such as Meniere's disease or Endolymphatic Hydrops, fluid pressure can shift periodically in the inner ear. When the fluid balance is disturbed, the pressure in one ear can suddenly go awry. In this case you have a large mismatch of information coming to the brain that can be quite incapacitating.

Contact us at lifemarkvestibular.ca - we can help!

Does Vestibular Rehab Help Ringing in the Ears?

What Causes Ringing in the Ears?

Ringing in the ears is referred to as "tinnitus" and is usually assessed by an ENT doctor and an audiologist

Ringing or buzzing in the ears is referred to as “tinnitus” and is usually assessed by an Ear, Nose, Throat doctor and an Audiologist.  Tinnitus is typically a symptom of a related problem with hearing nerves, different parts of the ear, or the part of the brain that interprets information.  According to the Tinnitus Association of Canada, “150,000 Canadians experience a degree of tinnitus that significantly affects their quality of life”.

The Canadian Academy of Audiology reports that the exact mechanism underlying tinnitus is not known, but that some of the causes can include:

• Outer ear disorders such as excessive ear wax, a hair touching the eardrum or a perforated eardrum
• Middle ear disorders such as an ear infection
• Inner ear disorders like damage due to noise exposure, hearing loss related to aging, or Meniere's Disease

How Does Vestibular Rehabilitation Differ from Tinnitus Treatment?

It is important to understand that Vestibular Rehabilitation DOES NOT address tinnitus.  If you have dizziness, unsteadiness and sensitivity to motion in addition to your hearing-related issues, then Vestibular Rehabilitation can be helpful with those symptoms, but you should not expect your tinnitus to change.  

Having said that, research is finding that some peoples’ tinnitus has an element of mechanical contribution to it that can come from the jaw-joint (TMJ) or neck.  If you seem to be able to alter your tinnitus with certain head, neck or jaw movements, posture, or trigger points, then it’s possible that therapy focused on these areas may help reduce tinnitus.  This is referred to as ‘somatically related tinnitus’ and research is showing positive outcomes with treatments such as TENS, therapeutic exercise, manual therapy, biofeedback/stress reduction and education. 

Contact us to find a vestibular specialist near you.

Why It Is So Important to Treat Dizziness

Dizziness and Doctor Visits

Dizziness is one of the top three reasons that people see their doctors.  A full 80% of people over age 65 have experienced dizziness and as many as 35% of Americans over the age of 40 have experienced a vestibular disorder.   BPPV  is the most common of all vestibular disorders and the most common cause of vertigo, or a ‘spinning’ sensation.

Dizziness and Seniors

Despite it being increasingly present as we age, BPPV frequently goes unrecognized, especially in seniors where dizziness is often assumed to be related to other health issues.  “Patients with unrecognized BPPV were more likely to have reduced activities of daily living scores, to have sustained a fall in the previous 3 months, and to have depression. These data indicate that unrecognized BPPV is common within the elderly population and has associated morbidity.”  [Oghalai JS1, et al. Unrecognized benign paroxysmal positional vertigo in elderly patients.  Otolaryngol Head Neck Surg. 2000 May;122(5):630-4.]

Dizziness and Injury

 Dizziness and unsteadiness are also very common complaints following whiplash disorder or concussion, and their presence is related to a longer recovery.  Vestibular involvement is often overlooked in post-concussion care.  The most current research and consensus statements suggest that combining vestibular rehabilitation and multimodal physiotherapy may optimize outcomes in those with persistent symptoms of dizziness, neck pain &/or headaches (McCrory et al 2013). 

Dizziness and Return to Work

According to a 2005 study conducted by Chamelian et al, dizziness is a negative predictor of return to work success. 

Seek Help!

Intervention is very important to avoid the downward spiral that can occur if dizziness disorders are not addressed. Some of the effects of untreated dizziness are:

• Falling, or fear of falling
• Decreased activities
• Depression and anxiety
• Memory and concentration issues
• Fatigue

It is extremely important to seek medical advice from a doctor knowledgeable in vestibular disorders or a vestibular rehabilitation specialist to treat dizziness and recover from any vestibular deficits that may be occurring.

Contact us to find a vestibular specialist near you.

What is the Vestibulo-Ocular Reflex and How is it Tested?

Ways Professionals Test Patients for Vestibular Dysfunction

Have you ever thought about how it's possible to see clearly even though our heads are moving? Most people think that the ears are just for hearing, but actually, there are nerve pathways between our inner ears and our eye muscles which drive our eye movements to keep things stable-looking when the head moves. This is called your Vestibulo-ocular Reflex (VOR). At anything other than very slow speeds, we need our inner ears to give the brain accurate information about head motion so that the brain can, almost instantaneously, tell the eye muscles what to do to keep images looking clear.  If this information is not correct, things will appear blurry or jumpy when moving – there is a term for this: oscillopsia.

Try it!  Look at a small number or letter at arm’s length in front of you and turn your head slightly back and forth quickly.  If your inner ears are working properly, your eyes are being told to move the opposite way of your head movement, at the same speed as the head movement, so that your target still looks clear for you.  A normal vestibulo-ocular reflex stabilizes your eyes no matter what movements your head is making.

How Vestibular Rehabilitation Professionals Evaluate the Vestibulo-ocular Reflex

There are ways that vestibular rehabilitation professionals can evaluate this reflex in patients.  One is called the Head Thrust or Head Impulse Test.  This is where we have you look at a distinct target (often just the tip of the tester’s nose) while the tester gives your head a very small but rapid and unpredictable movement.   We look for how well you keep your eyes on the target, and if there is an error in a particular direction of movement, it suggests a problem with the reflex, and helps us figure out what part of the inner ear isn’t doing its job.   Testing can also be done by testing what is called Dynamic Visual Acuity (DVA).  This is where your ability to read a particular eye chart while the head is not moving, is compared to your ability when the head is being turned back and forth at at least 1 Hz (one back and forth per second).  Depending upon how much your ability to read the chart worsens when moving, this can also indicate problems with the vestibulo-ocular reflex (VOR).  There are also computerized versions of this type of testing for greater precision.

Testing the VOR is only one of many things we evaluate in those with dizziness and balance disorders, but it is a key part of the testing.  This is because it can give us an idea whether or not your ears are sending your brain accurate information about your head movements, and if not, how this is affecting your ability to see while you are moving – which is pretty important!

Feel free to contact us – we are here to help you!

How Can the Inner Ear Make Me Unsteady?

Helping You Understand the Inner Ear

The ear is for hearing isn't it? I've been told that it is involved in balance and that ear problems can make you unsteady. How does that work?

Inertia, Gravity and Otoconia - Detecting Our Head Movements and Positions

In addition to the hearing organ, the inner ear contains the vestibular apparatus, which detects all head movements and positions.  This apparatus includes organs that contain calcium carbonate crystals (otoconia, or “ear rocks”) in gel.  Sensory hairs poke into the gel, so when the weight of the crystals shifts the gel due to linear acceleration, deceleration or tilt, the hairs get deflected.  These hairs are attached to nerve endings, so when they get moved, a signal is relayed to the brain telling us about what sort of motion is taking place and what orientation the head is at with respect to gravity.  The brain then uses this information to orient our eye position so that we can see clearly, and to tell our bodies what adjustments to make in order to keep our balance.

So if you are stopping or starting at a light, beginning to going up or down in an elevator, rocking on a boat, or just tilting your head and body a little, you can thank this part of the inner ear for helping you understand what is happening.   If these organs are not working properly in one or both ears, then you won’t be getting accurate information about your head position or certain head movements, in which case it’s pretty easy to see how this could make a person feel unsteady!  If your inner ear(s) aren’t telling you accurately where upright is, and if this information isn’t matching what your eyes see or your body feels, then you will likely feel off-balance.   (The inner ear also contains organs that don’t rely on gravity but instead detect angular head movements.  Problems here can create dizziness and vertigo, and this area will be explained next time.)

Fortunately, well-trained vestibular rehabilitation therapists can help people compensate for inner ear problems and improve their balance and orientation.  If you or anyone you know is experiencing dizziness or imbalance, feel free to contact us – we are here to help you!  

You can also find out more information about the inner ear balance system at the Vestibular Disorders Association .

How We Help BPPV in Older Adults

BPPV a Common Cause of Dizziness in Seniors

BPPV happens when loose crystals (otoconia) fall out into one of the canals

One of the most common causes of dizziness in seniors is Benign Paroxysmal Positional Vertigo, or BPPV.  This happens when calcium carbonate crystals (otoconia), that we all have in one part of the inner ear, become displaced into one or more of the inner ear’s semicircular canals. When otoconia move into one of the inner ear’s semicircular canals where they aren’t supposed to be, that canal sends different information to the brain about certain head movement than the other ear.  Both ears should be saying the same thing about what our head movements are, and they should be agreeing with what our eyes are seeing and our joints are feeling.  When there is a mismatch in these systems, it makes us feel dizzy.  BPPV is the most common cause of vertigo, which is an illusion of the room spinning or moving.

What Happens in the Inner Ear When the Room Starts Spinning?

Taking apart what's really happening to a BPPV patients as they experience vertigo can help patients to feel less frightened by it. The start of the problem often happens at night when a person is laying down.  Loose crystals can fall out into one of the canals, and when the person gets up in the morning these crystals are trapped out in the canal.  From that point forward any time the person moves their head into a position where gravity moves the loose crystals, that canal sends a message to the brain that is an error.  The most commonly provoking movements are getting in or out of bed, rolling over in bed, bending, looking upward and quick head movements.

Because of the connections between our inner ears and our eye muscles, during the time the crystals are moving, the incorrect signal makes our eyes move in a way that makes it appear like the room is spinning.  In the most common form of BPPV, the spinning only lasts until the crystals stop moving because they’ve reached the lowest point in the canal, which takes less than 1 minute.  If things are spinning longer than 1 minute, it is either a rarer form of BPPV called cupulolithiasis, or it is a condition other than BPPV.  A well-trained Vestibular Rehabilitation Therapist, ideally using special goggles allowing for a magnified look at your eye movements, can help you determine whether or not you have BPPV, and if so, what form you’ve got and what canal the loose crystals have moved into.  This then determines the treatment maneuver that should be used.

How We Treat Bening Paroxysmal Positional Vertigo (BPPV)

To help sufferers of BPPV a vestibular rehabilitation professional uses techniques to locate the crystals that are out of place and employs maneuvers to reposition them back to the correct chamber with the help of gravity.  Typically after 1-3 visits peoples’ BPPV is corrected.   Sometimes people have some mild sensitivity to motion and/or some balance issues that persist after the BPPV is cleared, but these are typically easily remedied with some simple home exercises.

If you or anyone you know is experiencing dizziness or imbalance, feel free to contact us – we are here to help you!

5 Symptoms of Vestibular Disorders

Changes to Parts of the Inner Ear and Brain Controlling Balance Can Cause a Vestibular Disorder

Problems with balance and spatial orientation can include difficulty walking straight or turning a corner

According to the Vestibular Disorders Association if the vestibular system gets damaged or altered, a vestibular disorder can result. The vestibular system includes the parts of the inner ear and brain that control eye movements, perception of head movement and balance. Therefore, problems in any of these areas or pathways can create dizziness, unsteadiness or visual issues.

Besides dizziness or vertigo, five of the most common symptoms of a vestibular disorder are:

1. Imbalance or falling
2. A rocking sensation
3. A sense of exaggerated or "after-motion" when you move
4. Nausea or vomiting
5. Visually provoked dizziness (see below), or blurry/'jumpy' vision during head movement

Problems with balance and spatial orientation can include a tendency to touch or hold onto something when standing, difficulty maintaining straight posture, clumsiness or stumbling, and difficulty walking straight or turning a corner.

With visually provoked dizziness, there can be sensitivity to light or certain types of computer monitors, poor depth perception, trouble reading or watching TV, and discomfort in busy visual environments like crowds, traffic, or stores.

Some people with an inner ear disorder can experience these as well as other symptoms, and an inner ear disorder can even be present without any obvious symptoms at all. It is important to seek professional help and get a vestibular assessment if you are experiencing any of the issues noted above.

Contact us - we are here to help!

Academy of Otolaryngology Position Statement on Vestibular Rehabilitation

Vestibular Rehabilitation recommended as a beneficial treatment for dizziness and balance disorders

Vestibular Rehab Recognized as a Valid and Beneficial Intervention for Individuals with Dizziness and Disequilibrium

We wanted to let our readers know that leaders in the field of inner ear disorders have reaffirmed their recommendation of Vestibular Rehabilitation as a beneficial treatment for dizziness and balance disorders. BPPV is the cause of approximately 50% of dizziness in older adults ^[1].

Recently at the Academy of Otolaryngology – Head and Neck Surgery’s 2013 Annual Meeting, the American Academy of Otolaryngology revised a position statement regarding Vestibular Rehabilitation. Their position now states that:

 “Vestibular Rehabilitation, or Balance Retraining Therapy, is a scientifically based and clinically valid therapeutic modality for the treatment of persistent dizziness and postural instability due to incomplete compensation after peripheral vestibular or central nervous system injury.”

“Vestibular Rehabilitation is a valid form of therapy for dizziness and imbalance resulting from the medical or surgical treatment of vertigo disorders and for acute vertigo or persistent imbalance that may result from a variety of peripheral vestibular disorders.”

“Balance Retraining Therapy is also of significant benefit for fall prevention in the elderly patient who may suffer from multiple sensory and motor impairments or for those who have sensory disruption with moving visual information.”

Many sufferers of dizziness, vertigo and imbalance have benefitted from Vestibular Rehabilitation, and we know how important this treatment is to them. It is also a very positive sign when the work of Vestibular Rehabilitation professionals is declared clinically valid by the Ear, Nose and Throat medical community.

^[1] Fife TD et al. Practice parameter: therapies for BPPV (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurol. 2008;70:2067-2074.

What to Expect During Vestibular Assessment and Treatment

Dizziness or Balance Disorders Can Be Caused By a Number of Different Conditions

At LifeMark we give clients different tests to narrow down what may be contributing to their dizziness

There are many, many different conditions that can contribute to dizziness or balance disorders. To help narrow down a clinical diagnosis, at LifeMark we give clients a number of different tests and evaluations. One of the first steps of the assessment process is the Dizziness Inventory that we ask clients to download from the website and fill in before your first appointment. This questionnaire allows us to identify difficulties that you may be experiencing because of your dizziness or unsteadiness, and gives us some valuable clues about what conditions you might be dealing with.

Vestibular Assessment Includes Infrared Video-Analysis of Eye Movements

LifeMark's vestibular assessment is extensive and includes infrared video-analysis of eye movements, which provides information about the inner ear and its connections in the brain. Many of these eye movement clues cannot be detected in room light. Treatment can involve a combination of stationary and moving balance retraining, gaze stabilization to help you focus during head movement, training for motion sensitivity, and canalith resposition manoeuvres for BPPV; the results are often dramatic.

The balance retraining component is also effective for clients who don't necessarily have a vestibular problem, but have muscle and joint problems, brain-related disorders, sensation problems, or vision changes affecting their equilibrium. LifeMark is actively involved in collecting outcome measures to make sure what we do is making people better, and is committed to utilizing the most current, evidence-based tests and techniques in its training and treatment programs.

Vestibular Assessment Also Includes Motion Sensitivity Testing, Static and Dynamic Balance Testing and TMJ Testing

As part of your vestibular assessment we go through many of these tests, as determined by the nature of your symptoms:

• We take a thorough history
• We take your blood pressure both when standing up and lying down
• We perform motion sensitivity testing, scoring both the intensity and duration
• We perform static and dynamic balance tests, to compare to normative and fall risk data
• We test for TMJ (temporomandibular joint disorder) and cervical spine mobility
• We screen for any serious problems with the following:

1. Cranial nerve scan
2. Vertebral artery scan
3. Carotid pulse
4. Carebellar tests
5. Scans for upper motor neuron lesions
6. Ligamentous stability of the upper cervical spine

What is Vestibular Rehabilitation?

Vestibular Rehabilitation is a proven, research-based branch of physiotherapy where specific individualized techniques are used to maximize the brain's compensation for vestibular pathology, or where manoeuvres are done to correct mechanical dysfunctions in the vestibular apparatus.

What Can Cause the Problems?

Vestibular disorders can come from pathologies in any area of this complex system. They can be insidious ("out of the blue") or due to factors such as trauma (motor vehicle accidents, falls, contact sports, blows to the head), infections, aging, medications, brain-related problems, or secondary to other diseases or injuries. Symptoms can include dizziness, imbalance, blurry vision, motion sensitivity, nausea, poor concentration, muscle guarding/restriction of movement, decreased activity levels or social interaction, anxiety and depression.

Home-Based Exercise is Vital to Your Vestibular Treatment

Repeating Movements That Provoke Dizziness Will Help You Recover From It

Many sufferers of dizziness are surprised to find that not doing the movements that make you dizzy will actually delay your recovery in the case of vestibular problems. An exercise program that repeats the movements that provoke dizziness can train your brain to compensate and help you to overcome it.

At LifeMark Vestibular Rehabilitation, we educate our clients in specific techniques that gently reproduce the symptoms so that the brain can see the error signals enough to allow it to compensate for dizziness problems. The underlying problem may still be there, but the brain can do an excellent job processing signals in a different way so that you no longer feel the symptoms in many cases.

After an initial assessment, we provide individualized treatment plans with exercises to help your specific situation. Some ways that home-based exercises can maximize central nervous system compensation are:

• By reducing motion sensitivity (habituation)
• By improving static / dynamic balance
• By improving gaze stability (adaptation)

Just as figure skaters or ballet dancers learn to suppress and adapt to signals from the balance organs when they spin that would make the rest of us dizzy, we teach clients how to help the brain process this information so that the sensation of dizziness is lessened or removed altogether. When you are practicing the brief but specific exercises at home, we would typically see you once per week over a 4-6 week period, after which treatment is either complete or may be weaned down.

Exercise Helps the Brain Compensate For Vestibular Problems

Low-impact aerobics, Tai chi or a walking program can also improve general fitness levels, strengthen balance, and expose you to movements that help your brain compensate for vestibular problems. The Vestibular Disorders Association does not recommend doing vestibular exercises at home without a diagnosis and personal treatment plan from a vestibular specialist. We are here to help!

Contact us to find a vestibular specialist near you.

Taking Good Balance for Granted

It's Not Until Dizziness Becomes a Problem That We Notice How Important Our Balance Is To Us

According to the Vestibular Disorders Association (VEDA), the body maintains balance with sensory information from three main systems:

• Vision
• Proprioception (touch sensors in the feet, trunk, and spine)
• Vestibular system (inner ear)

The Brain Integrates Sensory Information to Help Us Keep Our Balance

These three systems send information to the brain, and in response, the brain figures out where you are in space and sends information to the eyes for steady vision, and to the muscles for balance. When your balance system is working properly, you feel normal when you are standing or moving around:

• you can keep your balance when you're doing different activities
• you can see everything clearly when you move around
• you don't give a second thought to whether or not you should move your head

But when the balance system isn't working, even small activities like walking on uneven ground or walking down the stairs can be challenging and even cause an accident.

When the balance system isn't working, walking down the stairs can be challenging

Conflicting Information to the Brain Causes Disorientation

If the brain is getting conflicting sensory information from the vestibular system, the eyes, muscles or joints, it is difficult to process it. The goal of vestibular rehabilitation is to correct problems in the inner ear, or create a treatment program for you that will help the brain re-establish the coordination between your inner ears, eyes, muscles and joints. 

Contact us with any questions you may have - we are here to help!