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!