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.