Vestibular Rehabilitation Therapy (VRT)
Vestibular Rehabilitation Therapy (VRT) is an individualised exercise- based programme for those suffering from central (brain) or peripheral (inner ear) vestibular problems. There is good scientific evidence to support VRT as a treatment option that is non-invasive and not reliant on medication.
The vestibular system- The inner ears relay information to the brain about head movement and position. The brain processes these messages along with information from vision and joint position sense from your ankles, knees, hips and spine. It then adjusts your eyes to maintain focus and posture to maintain balance while you are moving. The vestibular system is extremely sensitive and fast and so when things go wrong a number of symptoms are experienced. These include:
- Dizziness (light headedness, spacey feeling)
- Vertigo (a sense of movement when there is none eg; spinning sensation or feeling of being on a boat)
- Feeling off balance, unsteadiness and increased risk of falling
- Decreased concentration, brain fog
VRT can help in:
Conditions affecting the peripheral vestibular system (inner ear) such as:
- Benign Paroxysmal Positional Vertigo (BPPV)
- Unilateral or bilateral vestibular hypofunction- this is where there is damage to one or both inner ears following a virus, surgery or drug toxicity
- Meniere’s Disease in the later stages where there is loss of inner ear function and balance problems
- Older adults with dizziness and/or balance problems and increased risk of falling.
Conditions affecting the central vestibular system such as:
- Strokes affecting the cerebellum (balance centre in the brain)
- Traumatic Brain Injury or concussion
- Vestibular migraine
- Motion sensitivity
- Anxiety induced dizziness.
The aims of VRT are to improve gaze stability, improve balance, decrease vertigo, dizziness and visual symptoms, decrease anxiety and increase fitness and activity levels. VRT exercises need to increase your symptoms to be effective. I structure your programme to progress exercises at a pace that you can tolerate
Benign Paroxysmal Positional Vertigo (BPPV):
BPPV is the commonest cause of vertigo especially in older adults. It is caused by calcium carbonate crystals breaking off the utricle in the inner ear and falling into one of the 3 semi-circular canals. These crystals then move in the canal with gravity when you change the position of your head (much like a marble rolling round a curved tube).
- Symptoms include: brief vertigo (spinning sensation) and unsteadiness on positional changes such as lying down, turning in bed, getting out of bed, bending and looking up, standing up from your chair and turning your head quickly. You may also have nausea, a fuzzy headed sensation, fatigue and decreased concentration.
- Diagnostic tests: involve lying you down quickly to provoke the vertigo as you get a corresponding eye movement (nystagmus) that enables the clinician to determine which canal the crystals have fallen into. I use specialised infra-red goggles that you wear so that I can record your eye movements on the computer.
- Treatment: Repositioning manoeuvres are the most effective treatment options for BPPV. These involve rolling you over with your head in different positions to use gravity to move the crystals out of the canal to be reabsorbed. Often only one manoeuvre is required to clear the BPPV. The most common of these manoeuvres is the Epley manoeuvre. Medication is only useful if you have severe nausea. It does not cure the underlying BPPV.
Vestibular tests for other conditions:
- General eye movement tests to test the central system (brain)
- Head Impulse Test- very quick head movements to test the vestibulo-ocular reflex (VOR). This reflex enables us to maintain focus while we move our heads quickly such as when crossing the road. This reflex is damaged when there is loss of function in one or both inner ears.
- Balance tests. Static tests are done with you standing still and dynamic tests are when you are moving.
- Vestibular questionnaires are used to get a baseline measure of how your symptoms are affecting your daily activities.
- Motion sensitivity testing. Different movements are tested to see if they provoke your symptoms.
Treatments for other conditions:
For conditions other than BPPV, I design an individualised treatment programme.
- For vestibular loss of function, the exercises are designed to retrain the VOR and/or promote reprogramming of your brain to promote central nervous system compensation for the loss of function. They include head, body and eye exercises to improve gaze stability and balance while you are moving your head.
- For hypersensitivity to movement the exercises are designed to desensitise the vestibular system using a progressive programme of movements that provoke your symptoms as you can tolerate them.
- Balance exercises when indicated.
Who provides VRT? In NZ it is predominantly Physiotherapists who provide VRT. Not all Physiotherapists are trained in this area so you need to find one who is.
How do you get referred? Any Health Professional can refer you (GPs, Neurologists, ENT specialists, other Physiotherapists, Chiropractors, Audiologists, Opticians etc. You can also self-refer. If I think further investigation is required, I will refer you back to your GP to arrange further testing with a Neurologist or ENT specialist.