What is the Epley Maneuver?

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

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

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

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

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

Don't Try the Epley Maneuver By Yourself

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

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

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

Read about why it is so important to treat dizziness.

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

Many Common Symptoms Between Concussion and Neck/Vestibular Injuries

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

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

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

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

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

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Vestibular Treatment for Concussion Management

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

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

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

High Success Proves Effectiveness of Vestibular Rehabilitation & Cervical Spine Physiotherapy

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

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

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

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

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!