Intro to Vestibular Disorders

Benign Paroxysmal Positional Vertigo (BPPV)

BPPV is the most common cause of vertigo and is characterized by dizziness (spinning or lightheadedness/sense of imbalance) with position changes. BPPV is caused by small crystals (otoconia) in your vestibular system/inner ear that are displaced into the semicircular canals. When you change positions, the crystals shift, causing your brain to think that you are spinning when you are not. The shift of the crystals causes nystagmus (quick rotary movements of your eyes that cause the spinning sensation). The symptoms of spinning typically last 10-20 seconds, but you may have motion sensitivity or nausea much longer.

Positions that typically induce symptoms include: lying down, sitting up from lying, bending over, or quick head movements (rotation or looking up)

Treatment for BPPV includes canalith repositioning maneuvers (see treatment strategies below) and usually resolves with the first treatment (1-2 maneuvers). Unfortunately, BPPV is recurrent, and once you have had an episode, it will likely reoccur again, but it may be years later and is usually not as intense as the first bout. The good news is you will be able to quickly recognize the symptoms and return to your physical therapist for 1-2 visits for resolution of your symptoms.

Vestibular Hypofunction

Vestibular hypofunction is a weakness of the vestibular nerve or the vestibular system itself that is caused by vestibular neuritis, vestibular artery ischemia, or labyrinthitis. Vestibular neuritis is an inflammation of the vestibular nerve, typically due to a virus (upper respiratory or gastrointestinal virus) that causes a spontaneous onset of vertigo, including spinning, nausea/vomiting for days typically followed by lightheadedness, and imbalance when not treated. Anterior vestibular artery ischemia is an occlusion of the vestibular artery that causes a spontaneous onset of vertigo and nausea/vomiting that lasts for days. Finally, labyrinthitis is an inflammation of the vestibular system due to an infection (viral or bacterial) that causes a spontaneous onset of vertigo and nausea/vomiting. The symptoms of labyrinthitis typically last for days and include auditory symptoms (hearing loss or ringing in the ear).

Treatment strategies include gaze stabilization, habituation, and balance training (see treatment strategies below).

Meniere’s Disease/Vestibular Migraine

Meniere’s disease is a disorder of the inner ear with unknown etiology that causes episodes of spontaneous vertigo lasting hours at a time. There is associated hearing loss, ringing in the affected ear (tinnitus), or a sensation of fullness in the ear. People with Meniere’s disease may benefit from balance training and recommendations for dietary changes and tracking to identify potential triggers for Meniere’s attacks.

Vestibular migraines typically present in individuals who have previously experienced migraines. The migraines do not always present with headaches and may have more visual auras, sensitivity to light, or dizziness associated with it. Patients with migraine-related dizziness may benefit from physical therapy if they have neck pain that is triggering the migraines or may benefit from dietary changes/tracking to identify potential triggers.

Concussion or Traumatic Brain Injury (TBI)

Dizziness following a concussion is very common and occurs in ~70% of cases. Dizziness can be due to BPPV, vestibular hypofunction due to trauma, motion hypersensitivity, migraines/neck pain or central vestibular involvement.

Other Vestibular Disorders

• Acoustic Neuroma/Vestibular Schwannoma

• Central Vestibular Disorders (stroke, multiple sclerosis)

Treatment Strategies

Canalith Repositioning/Epley Maneuvers for BPPV

Treatment for BPPV involves canalith repositioning maneuvers (CRM) to move the crystals out of the semicircular canal and back in the vestibule. The most common CRM is the Epley maneuver which removes crystals from the posterior canal, but there are other maneuvers for crystals in the horizontal canal and cupulolithiasis where the crystals adhere to the semicircular canal.

CRMs are usually effective in the first 1 or 2 repetitions but can take as many as four repetitions in some cases or for patients with BPPV in both ears.

Gaze Stabilization

Gaze stabilization exercises are used to improve the vestibular-ocular reflex to improve symptoms of oscillopsia. Oscillopsia is a condition that occurs with vestibular hypofunction or central vestibular dysfunction and is characterized by an ability to maintain visual stability with movement. For example, patients describe feeling like things may be jumping up and down while walking or a sensation that their eyes are not moving in rhythm with their head or lagging behind.

Habituation

Physical therapists use habituation exercises to stimulate your vestibular system to reduce sensations of motion sensitivity, lightheadedness, and imbalance over time. The activities strategically provoke your symptoms of dizziness to a mild intensity to gradually condition your vestibular system to tolerate position changes/head motions. Once the exercises no longer cause symptoms, your physical therapist will progress them as needed to help you return to your normal activities.

Balance Training

Balance training may include static tasks to improve balance reactions, including balance with eyes closed, on a foam surface or varying degrees of support. It also may consist of more dynamic activities like walking with head turns, bending down to pick things up, etc. Your physical therapist will take information from your initial evaluation to determine what balance training is right for you and progress difficulty over time.