Dizziness and Balance Disorders-Home Page
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About Dizziness and Balance Disorders
Difficulty in Management of Symptoms
Therapy Intervention for Symptom Management
Vestibular Rehabilitation Therapy-History
Diagonostic Testing Prior to Therapy
The difference Between VRT and PT
Typical Course of Vestibular Rehablilitiation Therapy
“Dizziness” and “unsteadiness” are two of the most common complaints heard by physicians. Sometimes people who suffer from these symptoms have a difficult time describing how they feel. Patients will often say they feel “woozy” or “wobbly” or “groggy” or “fuzzy.” Others report they feel like they “stagger” when they walk or that they appear “drunk” or “tipsy”. There are a multitude of legitimate medical problems that could cause these complaints and many of them can be difficult to properly identify through standard office testing. When a physician tries to identify a source of dizziness or unsteadiness, they will typically give consideration to things like blood pressure (high or low), blood sugar (high or low), dehydration, poor circulation, neurological disorders, cardiovascular disorders, musculoskeletal disorders, vestibular disorders, tumors, allergies, medication side-effects, age-related changes, hormone-related changes – the list can seem endless. Recent studies have shown that an individual with a true balance disorder will see 4-6 doctors before receiving a proper diagnosis. Many patients will give up efforts to resolve their symptoms. Often the symptoms will be incorrectly attributed to age. Too frequently, symptoms go untreated and result in accidental injuries.
In the past, the standard medical treatment for symptoms of dizziness, vertigo and even disequilibrium was the prescription of certain medications such as Meclizine, Bonine, Antivert, Dramamine, Scopalamine and Phenergan. Unfortunately, all of these medications, although they are still considered “the standard therapy” in the treatment of dizziness, actually list “dizziness” as a typical side effect. Most of the medications act to impair or decrease balance reactions. This action potentially places the dizzy, unsteady person at a higher risk for falls. Long term treatment with these drugs can prevent central compensation (e.g. prevent the brain from compensating and helping control the symptoms). Back to Top
Although specific medication can be helpful for acute or severe symptoms, research has shown that the most effective medical approach for resolving symptoms of dizziness or unsteadiness is the timely prescription of a diagnosis-specific, symptom-driven, and fully individualized exercise regimen. Physical Therapists trained in this specific field of exercise – “Vestibular Rehabilitation Therapy” – can perform a comprehensive assessment of the structural and functional components of an individual’s balance system. The therapist will then use the results of these and other specific vestibular tests to design a program of progressive exercise that will strategically improve balance reactions as well as overall safety and stability. There is a strong home-program basis to this therapy approach, as well as a strong emphasis on the development of strategies an individual can use when feeling symptomatic. The eventual incorporation of exercise principles into an individual’s ADL’s – Activities of Daily Living – ensures the strongest, most long-term maintenance of the progress that was achieved during the therapy process. Back to Top
Although Vestibular Rehabilitation Therapy has only recently gained international acceptance, the concept – of using an exercise regimen based on coordinated head, body, and eye movements to treat vestibular disorders – is actually over 60 years old. In the mid 1940's, an English Ear, Nose and Throat (ENT) doctor, Sir Terence Cawthorne, observed that some of his patients who suffered inner ear injuries recovered sooner than others. When he investigated this anomaly, he discovered that by simply participating in routine exercise, especially those that involved head and body movements, his “dizzy” patients reported feeling better. In cooperation with a Physical Therapist, F.S Cooksey, he developed a regimen of exercises known as the Cawthorne-Cooksey Exercises. Modified versions of these exercises are still in use today.
In the late 1960's, the discovery was made of free-floating particulate debris (otoconia) in the semicircular canals of the inner ear. The particles were made of calcium carbonate and were found in the ears of symptomatic as well as asymptomatic individuals. There was, however, a definite difference in the particle accumulation found in patients who complained of positional ( or movement-induced) vertigo. This discovery led to the development of the Brandt-Daroff Activity in the 1980’s and eventually to the Particle Repositioning and Liberatory Maneuvers by Alain Semont and John Epley in the1990’s.
Since the resurgence of interest and research in vestibular/balance rehabilitation in the mid 1980's, literally hundreds (if not thousands) of research articles have been published in Otolaryngology, Neurotology, Neurology, Sports Medicine and Physical Therapy journals. The overwhelming conclusion of the studies strongly supports the benefits of Vestibular Rehabilitation Therapy as a management strategy for patients with vestibular dysfunction as well as other disorders of the balance system. Back to Top
Prior to receiving an assessment by a Vestibular Rehabilitation Therapist, a person who suffers from symptoms of dizziness, vertigo and/or unsteadiness will be scheduled for a visit with Dr. Krueger. He will perform a thorough interview and medical evaluation to rule out any of the more serious causes of these symptoms. Once he has determined that the cause of symptoms are related to a diagnosis that can be treated by therapy, he will schedule the patient for a comprehensive balance testing battery which will include: Videonystagmography (VNG), Vestibular Autorotation Testing (VAT), Computerized Dynamic Posturography (CDP) and Vestibular Evoked Myogenic Potential (VEMP). The results of these tests will provide Dr. Krueger with information he can use to identify possible causes of symptoms and in formulating a working diagnosis. The tests also serve to establish baseline data that can be used to measure any future changes in symptom presentation. Back to Top
After determining candidacy for balance or dizziness therapy services, an appointment will be scheduled for a comprehensive vestibular rehabilitation therapy (VRT) assessment. This initial VRT session typically takes 1-2 hours and involves a thorough interview, a baseline assessment of functional balance and mobility and the identification of any extraneous factors that could possibly be prolonging current symptoms. Quite often, it is the successful combination of test results and “symptom behavior” that points the way to each individual’s needs and therapy profile. If there are particular movements that cause or worsen symptoms of dizziness or unsteadiness, the vestibular therapist will dissect those movements in order to identify any crucial components that may need correction. Back to Top
Retraining of balance reactions and resolving the “error signals” that result in symptoms of dizziness or vertigo is a highly complex and multifactorial procedure that cannot be accomplished with therapy visits alone. The patient who attends vestibular rehabilitation therapy is often told “It’s not what you do here, but what you will now do for the rest of the day that makes you feel better”. Retraining balance requires more than just “getting stronger”. It requires more than just “walking more” or “being more active”. Balance retraining has to focus on the components of upright stability that have failed to adapt or to compensate for the changes experienced by the body.
Taking into consideration the “balance pyramid” (the sensory inputs provided by the eyes, ears and feet) proper VRT assesses the baseline function of all of these individual systems, how well they interact together to create reflex balance reactions and then designs specific exercises to improve the areas that are weak. If an individual has a tendency to depend on one system more than another, therapy will be directed at reducing their dependence on that system for balance maintenance. Back to Top
Most courses of Vestibular Rehabilitation Therapy last 4-6 visits – over a span of 4-6 weeks. Less time is typically needed for resolution of positional vertigo (BPPV); more time is needed for patients with multiple concurrent medical problems or with limitations of the visual (cataracts, macular degeneration, blindness) or somatosensory (peripheral neuropathy, peripheral vascular disease of the legs, arthritic ankle/knee/hip joints) systems. All follow-up visits with the vestibular therapist will involve reassessment of balance status and progression of your individual home program to compensate for any advances made since your last visit.
Once your therapy course is completed, strategies will be discussed regarding what to do on a daily basis to maintain the progress you have made and to possibly prevent any further impairments of your balance. Most of the strategies are easily incorporated into your daily routine and will not require any special equipment or lengthy exercise sessions.
Quite often when an individual has completed a course of Vestibular Rehabilitation Therapy, they will visit with the vestibular therapist periodically in order to ensure that their routine activities are continuing to support their balance. They may also use this revisit to obtain ideas for further enhancement of overall safety and function.