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.

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

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!

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!

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!

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.

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.

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!

Why Vestibular Rehab?

How Many People Experience Dizziness?

Dizziness is among the top three reasons why people see their doctors, and vestibular disorders can affect people of any age. Approximately 35% of Americans over age 40 have experienced a vestibular disorder.

80% of people over age 65 have experienced dizziness, and Benign Paroxysmal Positional Vertigo (BPPV) - when crystals get displaced into the semicircular canals - is responsible for at least 50% of dizziness in seniors. BPPV is also the most common vestibular disorder, and fortunately, the most straight-forward to treat.

People who go untreated for their dizziness problems may risk experiencing depression, anxiety and a higher chance of falling. In addition, if it's hard to get out of bed or move around without feeling dizzy, there is also a risk of becoming less physically active or not active at all.

Untreated dizziness problems can lead to isolation

Effects of Dizziness

Dizziness can lead to:

• increased fear of falling or increased risk of falling
• less mobility, which leads to isolation and deconditioning
• anxiety and depression
• increased memory and concentration issues
• less likelihood of experiencing positive outcomes in other areas of treatment

Sometimes people who are experiencing dizziness may adopt new ways of moving to try and avoid the feeling of dizziness or whirling. They might move very slowly or swivel their whole body instead of their head in order to look at something, or look down at the ground all of the time to try to get their bearings. But these patterns can give people headaches and muscle tension, and just tire them out that much more. Research shows that avoiding the sensation of dizziness at all costs, actually slows down recovery.

Vestibular Rehab is an Exercise-Based Approach

Vestibular rehabilitation therapy is an exercise-based approach that retrains the brain to process coordinated information from the vestibular system, proprioception, and vision.

Research shows that Vestibular Rehabilitation is:

• applicable to anyone of any age
• effective regardless of how long a person has had the dysfunction
• has no reports of adverse effects

If you are dizzy or experiencing vertigo, please contact us for more information.

Why Am I Dizzy?

Spinning, Dizziness or Falling Can Mean the Complex System That Looks After Our Balance Isn't Working Properly

Dizziness can be caused by the balance organs of the inner not working properly

Our bodies have a complex system to look after our balance that includes the inner ear, brain, vision, muscles and joints. If any part of this system isn't functioning, the result can be a feeling of spinning, dizziness or falling. Many adults feel dizzy, and there can be many possible reasons, but one of the more common culprits is that the balance organs of the inner aren't working properly, or that some parts of the central nervous system that process information about balance aren't working properly.

The word 'dizziness' means different things to different people. People using that word may be trying to describe vertigo (spinning), feeling faint or light-headed, disequilibrium (loss of balance) or unsteadiness, falling, nausea, a sense of exaggerated motion or just feeling "off". The better you are able to describe what you mean by 'dizziness', the easier it is for your medical provider to try to diagnose what is going on.

Vertigo Usually Indicates a Problem with the Function of the Inner Ear

According to the Vestibular Disorders Association (VEDA), if you have vertigo (a sense of spinning or whirling), especially when you tilt or move your head around, that is likely a sign of a problem with the function of your inner ear. On the other hand, dizziness can mean that there is a different type of vestibular problem or other issues such as vision, metabolism, neurological, psychological or cardiovascular. Since there are so many different types of dizziness and possible disorders that dizziness can be a result of, it is sometimes challenging for medical professionals to diagnose, and difficult and frustrating for patients until help is found.

Many things can be the cause of dizziness, from ear infections or trauma to an ear, to Meniere's Disease, to medications, to age-related degeneration, to central processing issues such as a stroke, to migraine-associated vertigo, to cardiovascular problems, to the neck, among other causes.

Assessment is Crucial in Finding the Cause of Dizziness and Vertigo

The assessment stage of vestibular treatment is crucial in trying to find the cause of dizziness and vertigo. At LifeMark Dizziness & Balance Program, we take a thorough medical history first and screen for neurological problems. Our vestibular assessment includes vestibular-ocular reflex testing, or testing of the integration between the inner ear and the eye muscle to see if you can focus clearly while your head is in motion. It also includes many tests using an infrared camera in blackout goggles to check for nystagmus, which is an involuntary eye movement associated with vestibular problems. We also evaluate your sensitivity to specific movements and positions, your balance, and the possibility that other areas are contributing to your symptoms like your feet or neck.

Contact us with your questions!